Comparison of IMRT and VMAT treatment techniques 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

I. Abstract 
II. Introduction 
A. In the past 3D Conventional Radiation Therapy planning was primarily
used for planning lung treatments and dose constraints were based
on Dose Volume Histograms (DVHs) of these plans.¹
1. Through advancements in
technology Volumetric Modulated Arc Therapy (VMAT) and Intensity
Modulated Radiation Therapy (IMRT) are now being used for
lung treatments.²
B. With these new forms of planning there is a risk for increasing
the percentage of the lung volume receiving a dose of 5Gy or more (V5) in
patients due to increased beam angles.³
1. When the V5 dose increases there becomes a higher risk for
radiation pneumonitis and other complications.⁴,⁵
C. When comparing IMRT to VMAT, does dynamic arc therapy produce
significantly greater low dose (V5) exposure as Planning Target Volume
(PTV) size increases compared to static IMRT.
1. Previous experiments have said V5 is not predictive
of radiation pneumonitis but did not examine if V5 levels are as high
as being delivered with dynamic arcs.
2. The lung V20 is defined as a percentage of the normal lung volume,
with the subtraction of the total lung from the tumor, which receives
radiation doses of 20 Gy or more. In previous experiments,
the percentage of the lung volume receiving a dose of 20 Gy or
more (V20) was looked at to evaluate the risk of pneumonitis.1
3. However, previous data suggests V5 must be looked at in addition to
V20.2
 D. The aim of this research was to determine if lung dose is significantly higher
in VMAT treatments versus IMRT and to spark future research within the
medical dosimetry field.
III. Materials and Methods 
A. Patients 
1. All patients selected for this research had centrally located lung
tumors that have a PTV between 40-400cc with doses prescribed at
55-65 Gy with no plans for before 2015.
a. The cases came from three different cancer centers.
b. Different types and stages of lung tumors were observed.
c. Lung tumors that are located laterally were excluded from
this study.
d. Lung patients with prior radiation had been excluded from
this study.
e. Patients that used V5 for optimization were also excluded
from this study.
2. All the patients were positioned/set-up in a similar fashion.
a. All the patients were positioned in the supine head-
first position for their CT simulation.
b. The patient's arms were positioned over their heads using a
T-Bar device.
c. A Vacuum-Lock bag was placed under their chest and
arms to provide stability and comfort.
d. The CT scan was then performed and the isocenter was set.
e. Tattoos were then placed in three locations: the anterior
chest and two lateral chests on the patient to mark the isocenter
to ensure reproducibility.
B. Contouring
1. After the CT simulation was performed, the patient's images were
uploaded into Pinnacle and Eclipse treatment planning systems to be
contoured by the radiation oncologists and medical dosimetrists.
 a. The radiation oncologists were responsible for contouring
the target volumes gross tumor volume (GTV), clinical target
volume (CTV) and PTV.
i.To create the PTV, the CTV was expanded 1.0 cm
superiorly and inferiorly and 0.5 cm lateral and
medially coinciding with the Radiation Oncology
Group (RTOG) 0617 Protocol.⁶
b. The medical dosimetrists oversaw the contouring of
the thoracic organs at risk
(OARs) following RTOG 0617 protocol contouring the spinal
cord, lungs, esophagus, heart and brachial plexus (Table 1).⁶
C. Treatment Planning 
1. Treatment planning was performed
using IMRT and VMAT techniques within the Pinnacle and Eclipse
treatment planning systems.
a. Applying proper technique depended on the tumor size,
tumor location, OARs and dose-tolerance criteria.
b. Six Megavoltage (MV) of energy was used for all IMRT
and VMAT plans involving the centrally located lung tumors
(Table 2).
c. The prescription varied between each patient within the
range of 45Gy-65Gy but remained the same between their
IMRT and VMAT plans (Table 2).
d. Conformal radiotherapy uses IMRT, which has a variety of
beam angles and number of beams (Table 2).
i.There were 7-9 beams used for each IMRT plan and
they were angled to avoid the spinal cord.
ii.IMRT improves dose conformity, but required longer
delivery time
e. The new type of IMRT is VMAT, which uses a variety of
arcs for beams, collimator angles and different rotational
 directions, clockwise (CW) and counter clockwise (CCW)
(Table 2).
i.Beams were arranged as partial arcs, single arcs, two
partial arcs or two full arcs with varying collimator
angles (Table 2).
ii.VMAT produces highly conformal dose distribution,
improves the delivery efficiency by reducing
treatment time and produces
accurate dosimetric calculations.
2. Radiation Therapy Oncology Group (RTOG) 0617 and radiation
oncologist preference were used to determine the constraints used for
creating the IMRT and VMAT treatment plans.
D. Plan Comparisons 
1. Plans using both VMAT and IMRT techniques
from previously generated patients were looked at for
comparison purpose.
2. Values of percentage of lung receiving V5 were recorded from
each plan to help gain a better understanding of each plan's quality.
a. Plans were compared based off several factors:
i.Technique used: VMAT vs IMRT
ii.Percentage of the lung volume receiving a dose of
5Gy or more (V5).
iii.Coverage of PTV.
iv.Prescription dose each plan was receiving.

IV. Results
A. The PTV coverage fell an average of 1.92% when switching from VMAT
to IMRT.
1. A paired T score of 2.5 validated that this is a significant
difference between planning types.
2. The IMRT plans still met initial or alternative planning objectives.
 B. All other organs met constraints and differences between techniques were
not statistically significant.
C. The V5 lung dose decreased an average of 3.0% when re-planned with
IMRT.
1. A paired T score of 1.34 failed to prove that this was a significant
difference.
2. The standard deviation for difference in V5 dose between
plans was 6.7%
a. This means between patients the resulting V5 dose was
highly variable.

V. Discussion
A. Coverage of the lung tumor PTV decreased when using IMRT versus
VMAT.
1. The plan was normalized to meet the PTV coverage requirements.
2. The use of VMAT allows the dose to come from more angles
increasing the dose received to the PTV.
B. All OAR constraints were met using both IMRT and VMAT.
1. Optimization of the OAR allowed them to remain below their dose
limits
C. The V5 lung dose for the VMAT plans was statistically the same as the
V5 dose for the IMRT plans.
1. The large number of beams needed to get coverage using the
IMRT treatment technique could have made the V5 dose for IMRT and
VMAT plans more similar.

VI. Conclusion
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Figures
 Tables

Table 1. The thoracic constraints used for patient treatment planning in IMRT and VMAT

Organ at risk Objectives

Spinal Cord Vmax (point dose) < 50 Gy

Vmax (0.03 cc) < 44-48 Gy

Lung V20 < 30-35%

V30 < 20-25%

Esophagus V45 < 33%
Heart V60 < 33%