Comparison of IMRT and VMAT techniques for the reduction of Spinal Cord dose in distal

esophageal patients: a case study.

Authors: April Moore and Ashley Walsh
Abstract- This is a retrospective case study comparing intensity modulated radiation therapy
(IMRT) and volumetric modulated arc therapy (VMAT) for patients with distal esophageal
cancer. The purpose of this study is to compare the dose to the spinal cord for each treatment
plan and to discover which plan offers the lowest cord dose while meeting the treatment planning
objectives. Five patients were selected; each patient had an IMRT and VMAT plan generated for
a prescription totaling 50.4 Gy. Dose constraints from the Emami dose volume histogram (DVH)
limitations were used to ensure dose to other critical organs and a target constraint of 95% of the
volume receiving prescription dose.1 The Pinnacle and Eclipse treatment planning software
(TPS) were used.
Keywords- Spinal Cord dose, IMRT, VMAT, esophageal cancer
Introduction- The standard options for treatment of esophageal cancers are currently surgery
alone or chemotherapy and radiation. The use of all three modalities is currently under clinical
evaluation.2 Historically the heart and lung dose have been the major concern in radiation
treatment planning for distal esophageal cancers. It has been shown that reducing the mean lung
dose below 20 Gy as well as volume of heart below 25 Gy will reduce the risk of radiation
pneumonitis and long term cardiac mortality.2 There have been prior studies that compare 3dimensional conformal radiation therapy (3D-CRT), IMRT and VMAT to discover which
treatment planning option can help reduce the heart and lung dose the most. These studies show
that these studies show that using IMRT can potentially decrease the volume of the lung
receiving 10Gy (V10) by 10%, the volume of lung receiving 20 Gy (V20) by 5% and a 2.5 Gy
decrease in the mean dose to the lung. Along with the benefits of IMRT planning, VMAT also
shows a 24% reduction in the volume of the heart receiving 30 Gy (31% vs 55%) when
compared to 3D-CRT.2 While these studies show a meaningful difference in the heart and lung
they do not provide evidence of lowering the dose to the liver or spinal cord volumes.2

Since the primary focus in research thus far has been the heart and lung, researchers in this
retrospective case study compared two treatment planning techniques, static IMRT to VMAT to
evaluate spinal cord dose as well as the dose to the neighboring organs.
Methods-The method of this retrospective case study was to evaluate 5 five treatment planning
techniques for patients with distal esophageal carcinomas. All patients had a biopsy proven
adenocarcinoma followed by chemo-radiotherapy. Pre-operative chemo radiation therapy is
generally given to a dose of 41.4-50.4 Gy with platinum or paclitaxel based chemotherapy. In the
United States, the most common definitive dose for esophageal cancer treatments are 50- 50.4
Gy..2This case study looked at a dose of 45Gy to the primary area of disease and affected lymph
nodes (PTV45Gy) and a 5.4 Gy boost to the primary disease (PTV50.4Gy) totaling 50.4 Gy. The
radiation was delivered at1.8 Gy/ day, 5 days per week over a 6 week period. All 5 patients had
both IMRT and VMAT treatment plans generated in the Pinnacle and Eclipse TPS. The
dosimetry of the plans was compared along with the target and organs at risk (OR).
Three of the 5 patients had a 4-dimensional (4D CT) simultaneously with their simulation CT in
order to observe any motion the target area might undergo. Respiration monitored CTs enable the
physician to accurately measure any motion of the target associated with breathing. The amount
of motion is taken into account in the internal target volume (ITV) structure. This structure will
allow a reasonable amount of dose to the normal tissue while minimizing geographical miss.3
Some clinics do not have the equipment necessary to perform a 4D- CT, in this case extra
margins need to be given to the simulation CT to take into account for possible motion.3 The
patients who did not have a 4D CT to monitor motion will have adequate margins added to the
target volumes on the treatment planning CT data set. During analysis of the 4D CT scans it was
found that two of the three had phase errors larger than 5 mm which falls outside of the
acceptable range therefore gating was requested. The first patient will be treated during the 3070% phase cycle and the second to be treated during the 20-70% phase cycle.
Esophageal cases not only show motion from respiration but from peristalsis or gastrointestinal
motion. Image guided radiation therapy (IGRT) is being used more frequently than in the past
because of this motion. The alternative to using IGRT would be to increase the target volumes
more to account for the possible motion. This would likely lead to an increase in side effects.4

All patients will have a cone beam CT (CBCT) performed before treatment 3 times a week to
ensure the location of the isocenter and kV on board imaging (OBI) the other 2 days. Image
guided radiotherapy can aid in quantifying and addressing soft tissue set-up and kv- cone beam
CT (kV-CBCT) is becoming more commonly used for treatment verification.5
Contouring/Treatment volumes-Using the radiation therapy oncology group (RTOG) 1010
protocol for guidance on critical structure contouring for distal esophageal cancer, organs
identified and contoured were the spinal cord, liver, bilateral lungs (minus the PTV), heart,
kidneys, liver, stomach and spleen. Typically the spinal cord would be contoured on all slices of
the PTV as well as a centimeter above and below, but since the spinal cord is the primary
concern in this study it was contoured on all slices of the CT scan to ensure the dose reflects the
total cord. Each lung is contoured individually on each slice as it appears on the CT scan and
then a Boolean operation was performed to combine the two structures while excluding the PTV,
to form the bilateral lungs. The heart, kidneys, stomach and spleen are contoured on each slice it
appears on the CT scan
Treatment planning/Beam arrangement-Five patients were looked at for this case study. Ten
plans total were generated, five in each technique (VMAT and IMRT). The prescription was
50.40Gy in 28 fractions. The plans all utilized a 6MV linear accelerator with IMRT capabilities
and treatment planning software capable of both IMRT and VMAT treatment planning. The
VMAT plans used both full and partial arcs with opposing rotations (clockwise,
counterclockwise) and the IMRT plans used a varying number of fields, 6-9 fields in total (Table
1). All isocenters are placed at the geometric isocenter of target (PTV).A target volume constraint
of at least 95% of the PTVs must be covered by the prescription dose.
Optimization process- Each patient will have both planning techniques optimized with the same
OR constraints. Using the Emami constraints the heart, right and left kidney will be evaluated by
dose to 33% of the volume as well as 67% and the max dose. The heart: 33% < 60Gy, the 67% <
45Gy and the max dose < 40Gy. The kidney: 33% < 50Gy, 67% < 30Gy and the max dose
<23Gy. The lung is evaluated by the mean dose of < 20Gy and the dose to 20% of the volume
(V20), which must be < 37%. The cord is evaluated by the max point dose of <45Gy.

Results-The coverage of each of the plans was compared using the D100, D95 and Dmean of the PTV
volumes (Table 2). A target volume constraint of at least 95% of the PTVs must be covered by
the prescription isodose line when using absolute dose, and all plans met this constraint (Figure
1). The average mean dose (Dmean) of the PTV45Gy was 47.48Gy for VMAT and 46.45Gy for
IMRT respectively. The average Dmean of the PTV5.4Gy was 5.5 Gy for VMAT and 5.55Gy for
IMRT respectively. The conformity index (CI= volume of tissue receiving prescription
dose/volume of PTV) and homogeneity (HI=D2/D98) were also evaluated.6,7 The average HI of
PTV45Gy was 1.05 for the VMAT plans and 1.07 for the IMRT plans; the average HI for PTV5.4Gy
was1.07 for the VMAT plans and 1.09 for the IMRT plans. The average CI of PTV45Gy was
97.63% for the VMAT plans and 97.38% for the IMRT plans and for the PTV5.4Gy the average CI
was 95.22% for the VMAT plans and 95.42% for the IMRT plans. The OR constraints were all
met (Table 3); the lowest max dose for the spinal cord was 21.79 Gy and lowest mean dose for
the spinal cord was 4.98 Gy, both found in plan five utilizing VMAT. The monitor units (MU)
were also assessed. It was found that overall the VMAT plans used about 16% less than the
IMRT plans. The lowest total MU was found in the VMAT plan two.
Discussion-Plan number five utilizing VMAT proved to be both the best on the spinal cord max
dose (21.79 Gy) and mean dose (4.98 Gy) while providing the PTV volumes with 98.65 %
prescription dose. The next best plan, number two, gave a max cord dose of 26.84 Gy (mean of
9.75 Gy) but only provided 95.71 % prescription coverage on the PTV volumes.
Conclusion-The VMAT and IMRT plans were similar in regards to PTV coverage and OR dose.
The spinal cord dose was however, less on the VMAT plans for these five retrospective cases.
The total MUs/treat times are much different therefore making VMAT more efficient than IMRT.
For centers without VMAT capabilities IMRT still shows to be as effective for target volumes
and sparing the critical structure.

References:
1

Emami B, Lyman J, Brown A, et al. Tolerance of normal tissue to therapeutic radiation.

Int J Radiat Oncol Biol Phys. 1991;21:10922

Lloyd S, Chang BW. Current strategies in chemoradioation for esophageal cancer. J

Gastrointest Oncol. 2014;5(3):156-165.
http://libweb.uwlax.edu:2097/10.3978/j.issn.2078-6891.2014.033

Patel AA, Wolfgang JA, Neimierko A, et al. Implications of respiratory motion as

measured by four- dimensional computed tomograohy for radiation treatment planning of
esophageal cancer. Int J Radiat Oncol Biol Phys. 2009;74(1):290-296.
http://dx.doi:10.1016/j.ijrobp.2008.12.060

Jensen AD, Grehn C, Nikoghosyan A, et al, Catch me if you can- the use of image
guidance in the radiotherapy of an unusual case of esophageal cancer. Strahlenter
Onkol.2009,7: 469-473.

Hawkins M, Aitken A, Hansen V, et al. Cone beam CT verification for esophageal cancer
impact of volume selected for image registration. Acta Oncol. 2011;50(8):1183-1190.

http://dx.doi:10.3109/0284186x.2011.572912
Feuvret L, Noel G, Mazeron J, et al. Conformity index: a review. Int J Radiat Oncol Biol

Phys. 2006;64(2):333-342. http://dx.doi:10.1016/j.ijrobp.2005.09.028

Kataria K, Sharma K, Subramanu V, et al. Homogeneity index: an objective tool for
assessment of conformal radiation treatments. J Med Phys. 2012;37(3):207-213.
http://dx.doi.10.4103/0971-6203.103606

Table 1: Beam arrangements for ten total retrospective plans defining number of arcs and static
fields used for the 45Gy and the 5.4Gy prescriptions.
45Gy:

Patient 1

Patient 2

Beam
Arrangement

6 co-planar
beams
3, 56, 311,
229, 142,
Gantry angles 180
Beam
Arrangement 1 partial ARC
ARC start and 250-150,
stop
150-205
5.4Gy:
Beam
Arrangement

Gantry angles
Beam
Arrangement
ARC start and
stop

Patient 1
6 co-planar
beams

Patient 3

Patient 4

Patient 5

5 co-planar
beams

7 co-planar
beams
180, 210,
295, 330, 30,
65, 150

6 co-planar
beams
180,340,
20,60, 100,
140

2 full ARCs
181-179,
179-181

2 full ARCs
3 full ARCs
3 partial ARCs
181-179, 179- 181-179, 179- 340-179, 197181
181, 181-179 340, 340-179

7 co-planar
beams
190, 215, 0,
180, 319, 54, 25, 50, 130,
223, 145
155

Patient 2
5 co-planar
beams

Patient 3
7 co-planar
beams
190, 215, 0,
3, 56, 311,
180, 319, 54, 25, 50, 130,
229, 142, 180 223, 145
155

Patient 4
7 co-planar
beams
180, 210, 295,
330, 30, 65,
150

1 partial ARC
250-150,
150-205

3 full ARCs
2 partial ARCs
181-179, 179- 340-179, 197181, 181-179 340

2 full ARCs
181-179,
179-181

2 full ARCs
181-179,
179-181

Patient 5
5 co-planar
beams
180, 40,
75,110,145,

Table 2: PTV coverage at prescription dose, mean dose (Dmean), dose at 100% (D100), dose at 95%
(D95), homogeneity index (HI) and conformity index (CI) defined for each of the 10 plans.
IMRT
PTV45 vol
(cm3)
PTV 45Gy
D100
D98
D95
Dmean
D2
HI
PTV1 CI

IMRT

Patient 1
548.74

823.25

681.08

Patient 4
1018.45

97.26%
43.5
45.16
45.59
46.65
48.6
1.08
97.30%

95.88%
44.88
44.51
46.82
46.02
48.19
1.08
0.962

99.70%
42.74
44.91
45.47
46.19
47.08
1.05
97.45%

99.59%
41.82
44.522
45.18
46.939
48.13
1.08
95.61%

Patient 1

Patient 2

Patient 2

Patient 3

Patient 3

Patient 4

Patient 5
134.34
99.04%
42.97
44.724
45.53
46.46
46.77
1.05
97.67%

Patient 5

PTV5.4 vol
(cm3)
PTV 45Gy
D100
D98
D95
Dmean
D2
HI
PTV1 CI

VMAT
PTV5.4 vol
(cm3)
PTV 45Gy
D100
D98
D95
Dmean
D2
HI
PTV1 CI

VMAT
PTV5.4 vol
(cm3)
PTV 45Gy
D100
D98
D95
Dmean
D2
HI
PTV1 CI

225.01
97.17%
5.33
5.41
5.46
5.57
5.86
1.08
98%

429.22
95.20%
5.01
5.28
5.44
5.52
5.97
1.13
97.20%

205.21
99.90%
5.24
5.44
5.47
5.56
5.62
1.03
99.55%

264.75
99.97%
4.24
5.15
5.14
5.55
5.38
1.04
84.78%

Patient 1
548.74

Patient 2
823.25

Patient 3
681.08

Patient 4
1018.45

98.35%
44.17
45.19
45.65
46.88
48.40
1.01
98.40%

96.04%
43.59
44.79
45.29
46.18
48.40
1.03
97.52%

99.78%
43.01
44.91
45.53
46.46
47.39
1.06
97.44%

99.88%
43.04
44.74
45.35
46.25
46.93
1.05
96.94%

Patient 1

225.01
96.04%
5.23
5.33
5.45
5.64
5.89
1.11
95.20%

Patient 2

429.22
95.38%
5.07
5.30
5.44
5.57
6.00
1.13
96.50%

Patient 3

205.21
100%
5.2
5.46
5.52
5.62
5.74
1.05
99.10%

Patient 4

264.75
99.99%
4.98
5.13
5.37
5.54
5.24
1.02
93.29%

75.89
95.33%
5.26
4.87
5.15
5.55
5.74
1.18
99.36%
Patient 5
134.34
99.65%
43.39
44.95
45.29
49.74
46.88
1.04
97.75%

Patient 5

75.89
97.65%
5.30
5.29
5.37
5.54
5.66
1.07
93.26%

Table 3: Organs at risk using Emami dose limits in Gy unless otherwise noted.
IMRT
Kidney Rt

Kidney Lt

Heart

Lung
Spinal Cord

Max
67%
33%
Max
67%
33%
max
67%
33%
mean
V20
max
mean
total MU
initial:
total MU
boost:
total MU

Patient 1
43.62
5.82
18.56
45.91
0.09
25.77
48.72
20.23
30.48
10.28
19%
36.20
15.42
340

Patient 2
24.86
1.51
6.97
46.1
0.05
18.28
54.54
20.78
35.46
14.61
31%
36.20
15.42
383.00

Patient 3
5.76
0.50
0.95
2.46
0.41
0.80
50.75
22.66
32.73
9.18
17.28%
42.36
18.81
958

Patient 4
46.68
9.92
15.48
50.1
12.08
16.18
54.01
16.6
29.59
8.41
19.96%
37.82
20.44
1050

Patient 5
0.73
0.18
0.28
0
0
0
52.33
12.30
18.41
6.65
2.06%
28.72
7.16
460

322

417

622

650

469

662

800

1580

1700

929

VMAT
Kidney Rt

Kidney Lt

Heart

Lung
Spinal Cord

Max
67%
33%
Max
67%
33%
max
67%
33%
mean
V20
max
mean
total MU
initial:
total MU
boost:
Total MU
avg max
cord
avg mean
cord

43.94
4.13
17.18
45.85
5.54
28.26
54.53
20.25
35.46
10.74
24%
42.83
10.87
355

28.74
2.4
12.36
47.03
6.32
19.78
54.50
16.51
21.56
16.72
21%
26.84
9.75
292

7.13
0.68
1.31
2.37
0.43
0.816
50.83
12.71
20.80
8.63
15.18%
33.04
12.51
582

45.41
11.52
17.55
49.24
10.02
15.77
52.81
16.60
24.21
8.41
12.20%
38.65
20.56
573

0.81
0.20
0.31
0
0
0
52.59
10.57
16.01
7.73
3.55%
21.79
4.98
479

331

292

620

519

475

686
39.52

584
31.52

1202
37.70

1092
38.65

954
25.26

15.42

12.585

15.66

20.50

6.07

Figure 1: Axial views of isodose lines showing planning target volume (PTV) coverage.