1

Dosimetric Comparison of a 3D Conformal Hybrid Arc Treatment Planning Technique

and Volumetric Modulated Arc Therapy (VMAT) for Mediastinal Lung Cancer: A Case
Study
Authors: Nicole Peckham R.T.(T), Stacey Song R.T.(T), Carlos Torres Teran R.T.(R), Nishele
Lenards, PhD, CMD, R.T.(R)(T), FAAMD, Ashley Hunzeker, MS, CMD
Medical Dosimetry Program at the University of Wisconsin – La Crosse
Introduction

In the field of medical dosimetry, a wide variety of techniques exist that medical
dosimetrists can apply to create patient-focused treatment plans that use high doses of radiation
to kill cancer cells and shrink tumors. As a rapidly evolving medical profession, a considerable
amount of research is constantly produced and published each year in an attempt to revolutionize
cancer treatment with new techniques. Some techniques, such as three-dimensional conformal
radiation therapy (3D-CRT), intensity-modulated radiotherapy (IMRT) and volumetric
modulated arc radiotherapy (VMAT) are well-established and have substantial bodies of research
behind them obtained through years of application that reinforce their use.
Each technique has dosimetric advantages and disadvantages associated with it. Due to
its simpler clearance process by insurance companies, 3D-CRT is recognized as the least
complicated and most affordable treatment option among the three. Three-dimensional
conformal radiotherapy techniques make it difficult to produce uniform dose distributions and
treatment target conformity leading to unnecessary irradiation of organs at risk (OAR).1
Intensity-modulated radiotherapy makes use of a multi-leaf collimator (MLC) and inverse
treatment planning to modulate beam flux intensity to improve target conformity and lower dose
to OAR.1 Greater tumor inclusion and OAR sparing capabilities have been demonstrated with
this technique compared to 3D-CRT.2 Volumetric modulated arc radiotherapy applies single or
multi-arc rotating irradiation in which the dose rate, position and speed can be modulated to
achieve ideal target conformity and treatment efficacy.1 This technique is considered to be
superior to IMRT for the treatment of specific malignancies, the drawbacks being a demand for
additional commissioning efforts, stricter quality assurance (QA) checks due to tighter tolerances
and testing of linear accelerator (LINAC) chain due to smaller fields and variation in dose rate
with gantry and MLC movement.2-3 To address treatment limitations that cannot be addressed by
these well-stablished methods, hybrid methods such as hybrid IMRT (H-IMRT) have been
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introduced. This technique allows most of the dose to the planning target volume (PTV) to be
delivered with 3D-CRT treatment while delivering the remainder of the dose with dynamic
IMRT (D-IMRT).4
Various studies were designed with the intention of assessing the efficacy of hybrid 3D
planning in treatment as well as its application to various anatomical sites. Basaran et al4
performed a dosimetric evaluation of 3D-CRT, D-IMRT and a combination hybrid-dynamic
conformal D-IMRT (H-DCIMRT) for treatment to the thorax. The study's conclusions indicate
that hybrid plans may be useful for conserving important lung volume while also safeguarding
the spinal cord, heart, and esophagus within dose tolerance limits.4
A different study by Pokhrel et al3 focused on mobile lung lesions and applied a hybrid
3D‐dynamic conformal arc (h‐DCA) planning technique using flattening filter‐free (FFF) beams
to minimize dose delivery uncertainties and interplay effects. Outcomes of the h‐DCA plans
included comparable conformity, target coverage, better tumor heterogeneity and exhibition of
no statistical significance in intermediate dose‐spillage compared to VMAT plans.3 Additionally,
a higher dose to the internal target volume (ITV), no dosimetric differences in terms of dose to
OAR, and no acute or late toxicity was demonstrated.3 The reduced monitor units (MU) and
beam-on time (BOT) required to deliver the same prescription dose translates to a reduction in
time the patient is on the table, thus improving patient comfort and potentially reducing errors
due to intra‐fraction tumor motion.3 The study concluded that this technique could be
incorporated to additional disease sites such as hypofractionated centrally located lung lesions,
stereotactic treatment of brain or abdominal/pelvis lesions including liver SBRT (stereotactic
body radiotherapy).3
Compared to more complex planning techniques such as IMRT or VMAT, 3D-CRT
techniques are less complex and less expensive. In many cases, IMRT/VMAT and a combination
of these techniques with 3D-CRT, can have desirable treatment outcomes, however, these
techniques are not available to all patients due to differences in insurance coverage. As patients
in need of urgent palliative treatment cannot afford to experience delays due to insurance
company approval disputes, a 3D-CRT treatment planning technique where 3D fields are
combined with a 3D conformal arc (3D Conformal Hybrid Arc) may offer a treatment outcome
comparable to VMAT. The problem is that there is a paucity of literature supporting 3D
conformal hybrid arc for radiotherapy treatment of mediastinal lung cancer. The purpose of this
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study was to compare 3D conformal hybrid arc to VMAT planning to achieve prescribed PTV
coverage while maintaining OAR dose constraints for mediastinal lung cancer patients. In this
study, researchers tested the hypotheses that 3D conformal hybrid arc plans would achieve a
maximum dose to the spinal canal of less than 45 Gy, mean doses of ≤ 20 Gy to the lungs and
heart, a mean dose of ≤ 34 Gy to the esophagus, and coverage ≥ 95% of the PTV receiving 100%
of the prescribed dose.
Case Description
Patient Selection & Setup
Patients in this retrospective study were mediastinal patients diagnosed with primary lung
cancer. Patients were identified from this pool based on separation (left, right, anterior, posterior)
by finding the average size, standard deviation, and narrowing down to those that fell within the
normal range based as per Chauvenet’s criteria for rejecting a reading. This study included
patients that were prescribed 60 Gy in 30 fractions and planned with VMAT. A total of 6 patients
fit the inclusion criteria. Patients that were either prescribed a different fractionation or multiple
dose levels, underwent treatment planning with conformal arcs, or had a separation that fell
outside of the normal calculated range were excluded from participation in this study.
Simulation Procedures
Patients were simulated using a Philips Big Bore CT scanner in a headfirst supine
position on a wing board with the arms raised outside of the treatment field. Each patient had a
Civco Knee Fix placed under their legs for comfort and a Vac Lok was used for immobilization
and reproducibility purposes. Patients were simulated with a five-point tattoo setup. After
receiving permanent marks on the skin surface, radiopaque markers were placed on each mark
for visualization during the scan. Per departmental procedure, a planning CT with IV contrast
and a 4DCT were performed using a 3 mm slice thickness.
Contours
Following the simulation, all contours were created using MiM Maestro version 7.3.3
software on the planning scan. From registered images on the scan, the physician contoured the
gross tumor volume (GTV) and added a 5 mm margin to create the PTV. The OAR on the scan
were contoured by the medical dosimetrist and consisted of the spinal canal, bilateral lungs, heart
and esophagus.
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Treatment Planning
Following target delineation, treatment planning was performed in RayStation version
11B by the medical dosimetrist. To maintain consistency among cases, all plans (except one) had
four static 3D fields, a partial conformal arc utilizing 6 MV energy, and were planned with the
intention of achieving a global maximum dose of 110% or below. For each plan, the conformal
arc was set-up first, with only 25% (1,500 cGy) of the prescribed dose (6,000 cGy) to avoid
overdosing the OAR. The treatment margin used was decided based on PTV shape and location,
ranging from 2 mm to 5 mm. The collimator angle was chosen based on PTV shape to allow
optimum MLC conformation. Each conformal arc was calculated to the PTV volume delivering
95% of the dose to 100% of the PTV. The gantry start angle was selected based on target
location, so if the target was right sided a partial arc starting on the left and rotating down the
patient’s right side was selected. The partial arc was necessitated by the LINAC’s inability to
deliver MU over a full arc with only 25% of the dose prescribed. Post arc length and treatment
margin delineation the optimizer was used to determine optimal dose rate and gantry speed. A
maximum dose of 1545 cGy and a minimum dose of 1505 cGy was assigned to the PTV for each
plan prior to optimizing.
A second beam set was then added to each existing plan and linked to the beam set of the
conformal arc; this allowed the optimizer to factor in the dose from the conformal arc while
creating segments for the static 3D fields. This beam set was given 75% (4,500 cGy) of the
prescribed dose (6,000 cGy). For ease of creation a four-field box template was inserted with the
same isocenter as the conformal arc. A 0 to 4 mm treatment margin was added to the PTV,
depending on the shape and location of the PTV. Gantry and collimator angles were adjusted for
each plan and each field to spare the OAR and shape dose. Each plan was calculated and
reviewed to determine any adjustments that would need to be made to the gantry angles.
Each field in each plan was copied and the original fields were weighted to 80% to force
the optimizer to weight each subfield 20%. The planning technique was then switched from 3D
to Static Multileaf Collimator (SMLC) and the primary beams were omitted from the
optimization parameters so that the optimizer wouldn't alter them. The optimizer was then reset
to remove the field shape from the segments. An objective function of a maximum dose of 6590
cGy and a minimum dose of 4500 cGy were assigned to the PTV prior to running the optimizer.
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After running the optimizer and calculating, each plan was fine-tuned by utilizing optimization
structures, manually adjusting MLC and re-optimizing depending on dose outcomes and
constraints. The prescription point changed to a dose specification point (DSP) that was dropped
in a volume of tissue within the PTV where it would meet the prescription.
Plan Analysis and Evaluation
All plans except for one met OAR constraints, as defined by QUANTEC, Mobius and St.
Charles Cancer Center. A dose volume histogram (DVH) was used to evaluate each plan for
target dose, OAR, and serve as a comparison between the 3D conformal hybrid arc and VMAT
plans. The spinal canal was measured as a maximum point dose in centigray (cGy), mean doses
of the heart, lungs (lungs minus GTV), and esophagus were measured in cGy, and coverage of
the PTV by 100% of the prescribed dose was measured in relative percent. Refer to Table 1 for a
summary of the patient data. All patient plans are prescribed to 60 Gy in 30 fractions.
The 3D conformal hybrid arc plan for patient 1 achieved lower mean doses of 70 and
1,453 cGy to the heart and esophagus respectively as well as greater PTV coverage of 96.04% by
100% of the prescribed dose. A difference of 34 cGy to the heart, 10 cGy to the esophagus, and
1.01% PTV coverage compared to the VMAT plan. The 3D conformal hybrid arc plan achieved
a greater maximum point dose of 3,707 cGy to the spinal canal, as well as a greater mean lung
dose of 915 cGy. A difference of 979 cGy to the spinal canal and 65 cGy to the lung. Both plans
met target and OAR constraints, resulting in a 3D conformal hybrid arc plan that is comparable
to the VMAT plan.
The 3D conformal hybrid arc plan for patient 2 achieved a lower mean dose of 1,578 cGy
to the lung as well as greater PTV coverage of 99.2% by 100% of the prescribed dose. A
difference of 18 cGy to the lung and 4.66% PTV coverage compared to the VMAT plan. The
plan achieved greater maximum point doses of 6,312 cGy to the spinal canal, as well as greater
mean heart and esophagus doses of 3,517 and 3,177 cGy respectively. A difference of 2,679 cGy
to the spinal canal, 1,546 cGy to the heart and 335 cGy to the esophagus. The 3D conformal
hybrid arc plan only met the mean dose constraint to the lung and coverage of the PTV by 100%
of the prescribed dose resulting in a 3D conformal hybrid arc plan that is not comparable to the
VMAT plan.
The 3D conformal hybrid arc plan for patient 3 achieved a lower mean dose of 83 cGy to
the heart as well as greater PTV coverage of 98% by 100% of the prescribed dose. A difference
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of 3 cGy to the heart and 2.89% PTV coverage compared to the VMAT plan. The 3D conformal
hybrid arc plan achieved greater maximum point doses of 2,785 cGy to the spinal canal, as well
as greater mean lung and esophagus doses of 776 and 2,310 cGy respectively. A difference of
847 cGy to the spinal canal, 24 cGy to the lung and 708 cGy to the esophagus. Both plans met
target and OAR constraints, resulting in a 3D conformal hybrid arc plan that is comparable to the
VMAT plan.
The 3D conformal hybrid arc plan for patient 4 achieved lower maximum point doses of
1,964 cGy to the spinal canal, as well as lower mean doses of 73, 744 and 1,159 cGy to the heart,
lung and esophagus respectively. A difference of 749 cGy to the spinal canal, 6 cGy to the heart,
10 cGy to the lung and 22 cGy to the esophagus compared to the VMAT plan. It also achieved a
lower PTV coverage of 96.18% by 100% of the prescribed dose compared to the VMAT plan, a
difference of 2.52%. Both plans met target and OAR constraints, resulting in a 3D conformal
hybrid arc plan that is comparable to the VMAT plan.
The 3D conformal hybrid arc plan for patient 5 achieved lower mean doses of 492 cGy
and 1,594 cGy to the heart and esophagus. A difference of 93 cGy to the heart, and 101 cGy to
the esophagus compared to the VMAT plan. It also achieved a greater maximum point dose of
2,942 cGy to the spinal canal, a greater mean lung dose of 636 cGy as well as lower PTV
coverage of 96.11% by 100% of the prescribed dose compared to the VMAT plan. A difference
of 587 cGy to the spinal canal, 52 cGy to the lung and 2.24% to the PTV. Both plans met target
and OAR constraints resulting in a 3D conformal hybrid arc plan that is comparable to the
VMAT plan.
The 3D conformal hybrid arc plan for patient 6 achieved lower mean doses of 746 and
1,272 cGy to the heart and esophagus respectively. A difference of 22 cGy to the heart and 215
cGy to the esophagus compared to the VMAT plan. The 3D conformal hybrid arc plan achieved
greater maximum point doses of 3,878 cGy to the spinal canal, a greater mean lung dose of 1,459
cGy as well as lower PTV coverage of 95.25% by 100% of the prescribed dose compared to the
VMAT plan. A difference of 168 cGy to the spinal canal, 89 cGy to the lung and 2.59% to the
PTV. Both plans met target and OAR constraints, resulting in a 3D conformal hybrid arc plan
that is comparable to the VMAT plan.
The results from the current study for mediastinal lung cancer patients were consistent
with results from Basaran et al,4 which revealed that 3D conformal hybrid arc plans may be
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useful for conserving important lung volume while also safeguarding the spinal cord, heart, and
esophagus within dose tolerance limits. Five 3D conformal hybrid arc plans met all OAR
constraints, five achieved a lower mean dose to the heart and four achieved a lower mean dose to
the esophagus compared to the VMAT plans. Similarly, results from the current study were
consistent with results from Pokhrel et al,3 which revealed that 3D conformal hybrid plans offer
comparable target coverage and no drastic dosimetric differences in terms of dose to OAR
compared to VMAT plans. Four 3D conformal arc plans achieved greater PTV coverage by
100% of the prescribed dose compared to the VMAT plans.
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Tables

Table 1. Patient data for 3D Conformal Hybrid arc and VMAT plans.
Patient # / Plan Spinal Canal Heart Mean Lungs Mean Esophagus PTV Coverage of
Type Point Dose (cGy) Dose (cGy) Mean Dose 100% Rx (%)
Dose(cGy) (cGy)
1: 3D Conformal 3,707 70 915 1453 96.04
Hybrid
1: VMAT 2,728 104 850 1,463 95.03
2: 3D Conformal 6,312 3,517 1,578 3,177 99.02
Hybrid
2: VMAT 3,633 1,971 1,596 2,842 94.36
3: 3D Conformal 2,785 83 776 2,310 98.0
Hybrid
3: VMAT 1,938 86 752 1,602 95.11
4: 3D Conformal 1,964 73 744 1,159 96.18
Hybrid
4: VMAT 2,713 79 754 1,181 98.7
5: 3D Conformal 2,942 492 636 1,594 96.11
Hybrid
5: VMAT 2,355 585 584 1,695 98.35
6: 3D Conformal 3,878 746 1,459 1,272 95.25
Hybrid
6: VMAT 3,710 768 1,370 1,487 97.84
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References

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