1

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 Hunzeker M.S., 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 1 full arc and 1 or 2 partial arcs with rotations of 100
-140 with the intention of sparing the contralateral lung without jeopardizing planning target
volume (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, 95% of the tumor volumes were covered by the 100% isodose line and
had comparable CI values. At the 95% confidence level, no statistical differences were found
between the 2 planning techniques.
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.

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When a lesion is inoperable, radiation therapy is one of the non-surgical modalities to provide
curative care or palliative relief.
If lesions are less than 5 cm in diameter, SBRT is a hypofractionated treatment that
delivers a high dose of radiation in 10-30 Gy per fraction.1-2 This procedure incorporates fourdimensional computed tomography (4DCT) and image guidance which both account for patient
respiratory motion. Traditionally, SBRT lung plans were created with three-dimensional
conformal radiation therapy (3DCRT), which uses 10-15 static fields to achieve a distribution
similar to an arc field. However, disadvantages of 3DCRT plans include long treatment times and
high toxicity to OR since lung lesions are often 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 OR 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 high dose region is generally higher than
desired. Non-coplanar VMAT plans are able to better decrease the global maximum dose 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.
On the other hand, a major disadvantage of non-coplanar plans is couch rotation, which
requires the radiation therapists to enter the room and briefly interrupts the treatment. This could
delay the treatment time and impact delivery accuracy as a result of patient movement. The
radiation 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 aim of this research was to evaluate the potential advantages of using non-coplanar
arcs in VMAT SBRT and the contribution of non-coplanar arcs in critical structure preservations

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and maximum point dose reduction.
Case Description
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 7 patients, 5 were
females and 2 were male.
Prior to treatment, each patient underwent CT simulation of 2 mm 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. The 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 4DCT 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
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 1 illustrates CTV and
PTV delineations. The contoured OR included the left and right lungs, total lungs (excluding the
CTV), esophagus, spinal cord, chest wall, heart, and skin. The superior limit of the heart began at
the bifurcation of the pulmonary trunk and was contoured until the last visible inferior slice. The
upper limit of the spinal cord represented where the brain stem ended to the level of lumbar
vertebrae 3. 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 gastroesophageal junction, passing the cardiac orifice. The skin, the most
superficial structure, had a uniform 5 mm depth from the body contour. A structure in which the

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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 override
artifacts in CT scans.
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 5 mm MLC
thickness. The field sizes were extended by a 1 cm margin away from the margins of PTV to
account for penumbra and low secondary electron scattering in lung tissue. 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 rotations in the opposite direction 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 noncoplanar 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 Nakamura5 in Figure
4. Nakamuras new conformity index (NCI) is the reciprocal of Paddicks CI which took into
consideration neighboring normal tissue avoidance.4 The dose 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 the
minimum dose delivered to 5% of the PTV (D5%), and the minimum dose delivered to 95% of the
PTV (D95% ) divided by prescribed dose (DP) then multiplied by 100 to obtain the percentage.6 All
of the plans shared the same DP and D95% since the plans had the same prescription dose of 5000

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cGy and the same normalization characteristic. A small HI value reflects sharp dose falloff
profile; therefore lower maximum dose and superior homogeneity. Maximum doses were noted
from the heart, esophagus, skin, and spinal cord to evaluate toxicities. The total lungs were
assessed based on volume receiving 5 Gy (V5Gy), 10 Gy (V10Gy), 12 Gy (V12Gy), and 20 Gy (V20Gy),
and the mean volume (Vmean). The chest wall was evaluated based on dose received by 30 cc
(D30cc) and 60 cc (D60cc) of the chest wall.
The mean and range for CI, HI, gradient, and maximum dose received by the PTV
(PTVmax) for the two planning techniques are demonstrated in Table 1. 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 non-coplanar. The mean lung
dose comparison between coplanar arcs and non-coplanar arcs is represented in Figure 5. In 5 of
the 7 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.7-9 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 were marginally higher than
the non-coplanar, 2149 MU in coplanar versus 2136 MU in non-coplanar. In addition, the total
treatment time of a non-coplanar plan was significantly longer than that of a coplanar plan.
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 maximum dose decreased from 1161 cGy in the coplanar
plan to 1126 cGy in the non-coplanar plan, a 2.7% improvement. Improved chest wall toxicities,
and esophagus were observed in the non-coplanar plans for 6 of 7 patients.
A Shapiro-Wilk Normality Test was performed to determine if each set of parameters
followed a normal distribution. The null hypothesis (H0) for this research assumed the samples
came from a normal distribution. If the data sets came from a normally distributed population,
the p-value should be greater than 0.05. Table 2 shows the p-values collected for each data set
where most of the data spanned from 0.0888 to 0.8350 indicating normal distribution behavior;
therefore H0 was accepted. However, the p-values of esophagus, and skin were less than 0.05;
therefore, they were not normally distributed.

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For data sets in which the Shapiro-Wilk Normality Test confirmed normal distribution, an
Analysis of Variance (ANOVA) Test was applied to compare two coplanar versus non-coplanar
plans through testing for significance. A Kruskal-Wallis H Test was applied to the esophagus and
skin to test for significance. At the 95% confidence level, if the p-value was less 0.05, it would
be indicative that there is a statistical difference between coplanar plans and noncoplanar plans. However, if the p-value was greater than 0.05, it would reflect no difference
between the 2 techniques. For the data, the p-values calculated were between 0.056 and 0.4652;
meaning there was a statistical difference between the 2 planning techniques. The results
reflected that the data sets for both coplanar and non-coplanar sets were fairly similar.
Conclusion
Zheng et al10 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. The research suggests surgery is currently the more superior modality,
however, additional research may demonstrate that by improving delivery techniques,,SBRT has
the potential to be equally as effective as lobectomy. There are advantages and disadvantages to
coplanar and non-coplanar plans, therefore it is difficult to determine which technique is better
due to other confounding factors such as patients health status and ability to cooperate during
treatment. This study included 7 patients and the most significant finding was the 8% average
reduction in heart dose observed in the non-coplanar technique. The current study demonstrated
no statistical significant differences between coplanar and non-coplanar techniques. A limitation
of the study was the small population of patients. Recommendation for future research would be
to increase the population of patients to include more data and potentially demonstrate more
significance and improve standard of care for Stage I, inoperable NSCLC patients.

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References
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http://dx.doi.org/10.1016/j.prro.2014.08.009
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http://dx.doi.org/10.1016/j.radonc.2006.07.009
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skull base tumors: analysis of treatment planning parameters. Radiat Oncol. 2006;46(1):1-10.
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5. Dhabaan A, Elder E, Schreibmann E, et al. Dosimetric performance of the new highdefinition multileaf collimator for intracranial stereotactic radiosurgery. J Appl Clin Med
Phys. 2010;11(3):197-211. http://doi:10.1120/jacmp.v11i3.3040
6. 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
7. 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
8. 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
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10. Zheng X, Schipper M, Kidwell K, et al. Survival outcome after stereotactic body radiation

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Bio Phy. 2014;90(3):603-611. http://dx.doi.org/10.1016/j.ijrobp.2014.05.055

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Figures

Figure 1. A transversal slice taken from the isocenter cut. The orange structure denotes the 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.

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

PTV ( volume ) x Prescription Isodose volume

NCI =
2
( volume of PTV covered by prescption Isodose volume )

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

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Mean Lung Dose

700
600
500
Coplanar
Non-coplanar

400

Dose (cGy)

300
200
100
0

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

Maximum Heart Dose

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

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Parameter
Conformity Index
Mean
Range
Homogeneity Index
Mean
Range
Gradient
Mean
Range
PTV max
Mean
Range

Coplanar

Non-Coplanar

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

Table 2. P-values of Shapiro-Wilk Normality Test

Mean
Techniques
Heart Esophagus
Lung

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

Chest
Wall

Skin

Conformity
Index

Spinal
Cord

Co-planar

0.0888

0.0928

0.0006

0.4732

0.0112

0.1780

0.8350

Non-coplanar

0.2335

0.1350

0.0017

0.2656

0.0139

0.4287

0.1268