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A dosimetric comparison of coplanar vs. non-coplanar VMAT SBRT techniques for

NSCLC: A Case Study
Authors: Doris Chen, B.S., Wael Makhael, B.S., R.T.(T), Nishele Lenards, M.S., CMD, R.T.(R)
(T), FAAMD, Ashley Pyfferoen M.S., R.T.(T), CMD
Abstract:
Introduction: The purpose of the study was to dosimetrically compare coplanar and noncoplanar volumetric modulated arc therapy (VMAT) techniques for early stage non-small cell
lung cancer (NSCLC) to determine whether non-coplanar plans could improve the quality of
VMAT stereotactic body radiation therapy (SBRT) lung treatments.
Case Description: Seven patients with left lung tumors of diameters 5cm were randomly
selected. Each coplanar arc plan had a full arc and 1 or 2 partial arcs 100 -140 with the
intention of sparing the contralateral lung without jeopardizing PTV coverage. The non-coplanar
arc plans were derived from corresponding reference coplanar plans with the exception of 15couch rotations. The non-coplanar arcs were rotated 15 in the opposite direction to reduce area
overlaps. Each patient had a coplanar and a non-coplanar plan that shared the same optimization
objectives. Each Individual plan was scored based on ease of treatment delivery, dose volume
histogram (DVH), conformity index (CI), homogeneity index (HI), and total monitor units (MU).
The DVH was used to evaluate the delineated organs at risk (OR), which included sum lungs,
spinal cord, esophagus, heart, chest wall, and skin,.
Conclusion: In all plans, the entire planning target volume (PTV) was covered by the 95%
isodose line and had comparable CI values.
Keywords: SBRT, VMAT, NSCLC
Introduction
Lung cancer is the leading cause of cancer mortality due to difficulty in early detection.
Lung cancer has an average five-year survival rate of 54% for localized tumors and an overall
average five-year survival rate of 17.8%.1 Patients with Stage I (T1 or T2, N0, M0) lung cancer
have the options of surgery, radiation, chemotherapy or a combination of treatment modalities.
However, one may refuse surgery or may not be a suitable candidate for surgical intervention.
When a lesion is inoperable, radiation therapy is the one of the non-surgical modalities to
provide curative care or palliative relief.

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If lesions are less than 5 cm in diameter, SBRT is a hypofractionation treatment
procedure that delivers high dose radiation of 10-30 Gy per fraction.1-2 This procedure
incorporates four-dimensional computed tomography (4DCT) and image guidance which all
account for patient respiratory motion. Traditionally, SBRT lung plans were created with threedimensional conformal radiation therapy (3DCRT), which uses 10-15 static fields to achieve a
distribution similar to an arc field. However, disadvantages of 3D CRT plans included long
treatment times and high toxicity to OR since lung lesions are located proximally to
radiosensitive structures (esophagus, heart, lungs, spinal cords, and chest wall) susceptible to
acute complications and late effects such as esophagitis, cardiomyopathy, pneumonitis,
myelopathy, and fractures.3 In the 3DCRT technique, preservation of ORs without compromising
dose distribution to the PTV is difficult to achieve since dose modulation could not be
accomplished with static fields.
When SBRT is delivered with VMAT technique, the arcs use gantry rotation and multileaf collimator (MLC) speed to modulate fluence and dose rate. As a result, VMAT plans are able
to localize high dose to a specific region and at the meantime, reduce high dose spillage to
uninvolved neighboring tissues or organs, shorten treatment times, and decrease MU. Coplanar
VMAT plans yield adequate PTV coverage but the hotspot is generally higher than desired. Noncoplanar VMAT plans are able to better decrease the global hot spot and improve conformity
since the planes of non-coplanar plans only intersect at isocenter. However, since non-coplanar
plans have different planar entrances and are spatially spread apart, integral dose and low dose
spillage might be negatively impacted. This can lead to higher integral dose and an increased risk
of secondary malignancies.
Contrarily, a major disadvantage of non-coplanar plans is room entrance to rotate the
couch. This could delay the treatment time and impact delivery accuracy as a result of patient
movement. Therapists would have to realign the patient to rectify potential set up errors that
stemmed from couch rotations. The potential for table collisions is a technical drawback of noncoplanar plans, especially when clearing full arcs.
The aims of this research were to evaluate (1) the potential advantages of using noncoplanar arcs in VMAT SBRT, and (2) the contribution of non-coplanar arcs in critical structure
preservations and hot spot reduction.
Case Description

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Patient Selection & Setup
Seven stage I (1A and 1B) NSCLC patients were chosen for this study. The lesions were
located centrally on the left lobe with diameters less than 5 cm and mean PTV volume of 58 cm.3
The mean patient age was 76 years old with a range of 62-89. Among the 8 patients, 5 were
females and 3 were male. Prior to treatment, patients underwent CT simulation of 2mm slice
thickness for the purpose of localizing the tumor and neighboring organs. The placement of
positional tattoos was performed under meticulous attention and extreme precision since SBRT
involves treating a small volume to with high doses. Patients were positioned supine on a
wingboard with a headrest to support the patients head. Arms were extended above the head
holding an indexed handle bar to allow for multiple gantry angles without treating through the
arms. For added comfort and reproducibility, the arms were relaxed against the wingboard. A
Vac-Lok immobilization bag was placed underneath the patient, which conformed to the patients
natural curvature. Respiratory gating or 4D CT was used to account for target motion in which
gating recorded the spectrum of the breathing cycle to determine the range of tumor movement.
The addition of PET scans helped to further identify the target volume based on the function of
biological processes.
Target Delineation and Contours
The radiation oncologist defined the clinical target volumes (CTV) that included the
primary disease, nodal involvement, and microscopic findings with abnormal attributes. The
CTVs were expanded 2.5 mm panoramically to create the PTVs. Figure 1illustrates CTV and
PTV delineations. The contoured OR included: the left and right lungs, total lungs (excluded the
CTV), esophagus, spinal cord, chest wall, heart, and skin. The superior limit the heart began at
the bifurcation of the pulmonary trunk, and contoured until the last visible inferior slice. The
upper limit of the spinal cord represented where the brain stem stopped to the level of L3. The
chest wall was a 20 mm expansion laterally, anteriorly, and posteriorly from the left lung. The
most superior aspect of the esophagus started from the cricoid cartilage and extended down to
the gastro-esophageal junction (GEJ), passing the cardiac orifice. The skin, being the most
superficial structure, had a uniform 5 mm depth from the body. A structure in which the total
lungs excluded the PTV was created to account for the optimization contradiction in region of
overlap shared by PTV and the left lung. Tissue density corrections were used to overwrite
artifacts in CT scans.

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Treatment Planning
The total prescribed dose was 50 Gy over 5 fractions at 10 Gy/fraction. Plans were
created using 6 MV beams for Varian iX linear accelerator commissioned with 5mm MLC
thickness. The field sizes had a 1 cm margin around the PTV in all directions to account for
penumbra. The coplanar VMAT plans had either 2 or 3 arcs with one of the arcs being a full arc
and the remaining being partial arcs, which varied between 100-140. Non-coplanar plans were
generated based on the reference coplanar plan, but with 15 couch kicks in the opposite
directions to minimize plane overlapping. For example, if the couch of the full arc was rotated
15, then the couch of the partial arc would be rotated 345. Figures 2 -3 show the orientations of
coplanar and non-coplanar arcs respectively.
The plans were optimized to meet OR constraints and to provide adequate coverage to
PTVs. Depending on the location of each lesion, a set of optimization structures that subtracted
any overlapping region with the PTV were created. The optimization structures helped eliminate
objective conflicts. A planning PTV (pPTV) structure was created to round out the jagged edges
of the original PTV defined by the radiation oncologist. All plans were normalized to 100% of
the prescribed dose covering 95% of the target volume.
Plan Analysis and Evaluation
Coplanar and non-coplanar plans were scored based on total MU, CI, gradient, HI, and
radiation toxicities to critical structures such as lungs, heart, esophagus, spinal cord, and chest
wall. The CI was computed using a Paddicks formula that was modified by Nakamura in Figure
4. Nakamuras new conformity index (NCI) is the reciprocal of Paddicks CI which took into
consideration neighboring normal tissue avoidance.4 Gradient of each individual plan was
computed using Paddicks formula, which was a ratio of the 50% isodose volume to the 100%
isodose volume. Homogeneity indices were calculated based on the difference between D5% and
D95% divided by DP then multiplied by 100 to obtain the percentage. In the HI formula D5%
represents the maximum or dose at 5% of the PTV volume, D95% denotes the minimum dose or
dose at 95% of the PTV volume, and DP indicates the prescription dose.5 All of the plans shared
the same DP and D95% since the plans had the same prescription dose of 5000 cGy and the same
normalization characteristic. A small HI value reflects sharp dose falloff profile; therefore lower
hot spot and superior homogeneity. Maximum doses were collected from the heart, esophagus,

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skin, and spinal cord to evaluate toxicities. The total lungs were assessed based on V5Gy, V10Gy,
V20Gy, and Vmean. The chest wall was evaluated based on D30cc and D60cc.
Table 1 shows the means and ranges of CI, HI, gradient, and PTVmax for the two planning
techniques. Non-coplanar plans had slightly lower mean values for CI, HI, gradient and PTVmax.
The amount of normal tissue receiving 105% of the prescription dose decreased when using noncoplanar. The mean lung dose comparison between coplanar arcs and non-coplanar arcs is
represented in Figure 5. In 5 of the7 patients, coplanar plans had significantly lower mean lung
dose whereas in Patient 3 and Patient 5, coplanar and non-coplanar plans yielded similar mean
lung doses. The data reflected non-coplanar plans were better able to reduce the dose to the
contralateral lung, specifically, V5Gy and V12Gy were decreased by 6% and 8% respectively.6-7
However, non-coplanar arcs did not affect V20Gy, which is the volume used to predict radiation
induced pneumonitis. Comparing the average number of MU per fraction, the MU of the
coplanar plan was marginally higher than the non-coplanar, 2149 MU in coplanar versus 2136
MU in non-coplanar. In addition, the beam on time of coplanar plan was significantly higher than
that of the non-coplanar plan.
Dosimetrically, the most significant finding was the reduction of dose to the heart. The
non-coplanar treatment plans yielded an average of 8% dose reduction in the heart. Figure 6
illustrates that in 5 of the 7 patients, non-coplanar plans were able to improve heart preservation.
Comparing the average dose to spinal cord, the coplanar plan was higher than the non-coplanar
plan. The spinal cord Dmax decreased from 1161 cGy in the coplanar plan to 1126 cGy in the noncoplanar plan, a 2.7% improvement. Improved chest wall toxicities, and esophagus were
observed in the non-coplanar plans for six out of seven patients.
Conclusion
Although non-coplanar plans may be able to reduce unnecessary radiation toxicities to
critical OR structures, the increase in treatment time may not be optimal for a physically weak
patient who cannot tolerate a slightly extended treatment. If meticulous attention is not paid to
couch kicks, a marginal blunder could miss a significant fraction of the tumor due to its small
size. Zheng et al9 found that the mean survival rates at 1, 3, and 5 years of patients treated with
SBRT were 83.4%, 56.6%, and 41.2% respectively in comparison to 92.5%, 77.9% and 66.1%
with lobectomy. This suggests currently surgery is the more superior modality, however, if more

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research is done on improving SBRT techniques the mode of delivery, SBRT has the potential to
be equally as effective as lobectomy. This small-scaled study is done on seven patients, if the
patient size increases, the data would be more significant and could potentially modify the
standard of care for stage I, in operable NSCLC.

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References
1. Onishi H, Shirato H, Nagata Y, et al. Stereotactic body radiotherapy (SBRT) for operable
stage I non-small-cell lung cancer: can SBRT be comparable to surgery? Int J Rad Oncol
Biol Phy. 2011;81(5):1352-1358. http://dx.doi.org/10.1016/j.ijrobp.2009.07.1751
2. Merrow CE, Wang IZ, Podgorsak MB. A dosimetric evaluation of VMAT for the treatment of
non-small cell lung cancer. J Appl Clin Med Phys. 2013;14(1):228-238.
http://dx.doi.org/10.1016/j.prro.2014.08.009
3. Oliver CT, Mustapha K, Patrice J, et al. Potential benefits of using non-coplanar field and
intensity modulated radiation therapy to preserve the heart in irradiation of lung tumors in the
middle and lower lobes. Radiother Oncol. 2006;80(3):333-340.
http://dx.doi.org/10.1016/j.radonc.2006.07.009
4. Collins SP, Coppa ND, Zhang Y, et al. CyberKnife radiosurgery in the treatment of complex
skull base tumors: analysis of treatment planning parameters. Radiat Oncol. 2006:46(1):1-10.
http://dx.doi.org/10.1186/1748-717X-1-46
5. Tejinder K, Kuldeep S, Vikraman S, et al. Homogeneity index: an objective tool for
assessment of conformal radiation treatments. J Med Phys. 2012;37(4):207213.
http://dx.doi.org/10.4103/0971-6203.103606
6. 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. http://dx.doi.org/10.1016/S0360-3016(99)00183-2
7. Barriger RB, Forquer JA, Brabham JG, et al. A dose-volume analysis of radiation
pneumonitis in non-small cell lung cancer patients treated with stereotactic body radiation
therapy. Int J Radiat Oncol Biol Phys. 2012;82(1):457-462.
http://dx.doi.org/10.1016/j.ijrobp.2010.08.056
8. Li Y, Liu B, Zhai F, et al. Dosimetric study of coplanar and non-conplanar intensitymodulated radiation therapy planning for esophageal cancer. Int J Med Phys. 2013;2(4):133138. http://dx.doi.org/10.4236/ijmpcero.2013.24018
9. Zheng X, Schipper M, Kidwell K, et al. Survival outcome after stereotactic body radiation
therapy and surgery for stage I non-small cell lung cancer: a meta-analysis. Int J Rad Oncol
Bio Phy. 2014:90(3):603-611. http://dx.doi.org/10.1016/j.ijrobp.2014.05.055

Figures

Figure 1. A transversal slice taken from the isocenter cut. The orange structure denotes CTV, and
the PTV, represented in blue is a 2.5 mm expansion of the CTV.

Figure 2. Coplanar arcs show that the beams rotate about the same axial plane.

Figure 3. Non-coplanar arcs with 15 and 345 couch kicks in the opposition direction show two
separate planes intersecting at the isocenter.
NCI =

PTV ( volume ) x Prescription Isodose volume

2
( volume of PTV covered by prescption Isodose volume )

Figure 4: Nakamuras revised CI formula based on Paddicks original formula.

Parameter

Coplanar

Non-Coplanar

Conformity Index
Mean
Range

1.30
1.13 to 1.5

1.22
1.14-1.30

14.5
9.4-19

14
8.9-17.9

4.6
3.4 to 5.8

4.4
3.4-6.1

117.2%
112.2-123

117.1%
109.4-122.6

Homogeneity Index
Mean
Range
Gradient
Mean
Range
PTV max
Mean
Range

Table 1: Conformity index, homogeneity index, gradient, and PTVmax comparison of the two
VMAT techniques.

Mean Lung Dose

700
600
500
Coplanar

400

Dose (cGy)

Non-coplanar

300
200
100
0

Figure 5. Mean lung dose comparison between coplanar and non-coplanar plans.

Heart Dose (Dmax)

CGy

1000
900
800
700
600
500
400
300
200
100
0

Patient 1

Patient 2

Patient 3

Patient 4

Patient 5

Patient 6

Figure 6. Maximum heart dose comparison between coplanar and non-coplanar plans.

Patient 7