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Joanne Li
Clinical Case Study
March 22, 2016
A Case Study of SBRT with VMAT for Lung Cancer Treatment
History of Present Illness: Patient BM is a 69 year-old female who was newly diagnosed with
stage I none small cell lung cancer (NSCLC) in February 2016. The suspicious nodule was first
noted on her routine follow up CT scan for tonsillar cancer in January. Subsequently, she went
through a PET scan and a lung biopsy. The PET scan showed hypemetabolic focus in the mass
which was suspected with primary lung cancer. Her diagnosis was finally confirmed by a lung
biopsy with the result of squamous cell carcinoma consistent with lung primary on February 24th
2016. Further pathological study of the biopsy sample was done to evaluate and confirm the
diagnosis of NSCLC. On her physical exam, BM did not have any palpable lymphadenopathy in
the following areas: Cervical, supraclavicular, infraclavicular, and axillaries. Bilateral lungs were
clear to auscultation. All the diagnostic tests and examinations revealed an early stage lung
cancer without lymph nodes metastasis. BM was a formal smoker for 50 years with an average
of 2 packs cigarettes a day. Since the diagnosis of the lung cancer on March 4th, she has cut
down to one pack per day. She reported that she did not inhale the smoke. She also had
unintentional weight loss of 30 lbs in the past year. Other than these, she was in her usual state of
health without acute distress at the time of diagnosis.
After going through the diagnostic tests for the final diagnosis, BM was referred to the
thoracic/foregut surgery department for consultation of surgical resection of the lung nodule.
However, she was not interested at the surgery and preferred to receive radiation therapy. On
March 3rd 2016, BM was referred to the radiation oncology department to meet the radiation
oncologist for consultation of further treatment plan through radiation.
Past Medical History: BM has significant medical histories of early stage tonsillar cancer and
coronary artery disease (CAD). She was treated for her tonsillar cancer with definitive radiation
therapy about 10 years ago in the other facility. As a result of the radiation treatment, she has had
difficulty swallowing and Xerostoma (dry mouth). After then, she has been on non-solid diet and
taking 2-3 bottles of ensure per day. She had a coronary artery bypass graft surgery with an
insertion of a stent 10-15 years ago. Other medical histories include hypothyroidism and chronic
obstructive pulmonary disease (COPD) which are all managed well with medications.

Social History: BM has a deceased sister at 33 year-old with unknown reason. She was married
with two sons both have no significant health issues. There is no other significant medical history
in her family reported by BM.
Medications: BM does not have any known drug allergies. Currently she is on levothyroxine 50
mcg, cevimeline, omeprazole, albuterol-ipratropium ACT inhaler.
Diagnostic Imaging: In January 2016, on a routine follow up CT scan of tonsillar cancer
treatment, it was first noted a 1.9 cm x1.7 cm speculated nodule in the left upper lung lobe. She
then went through a PET scan on January 29, 2016 which was found hypermetabolic focus in left
upper lobe mass compatible with a primary lung cancer and in the right mandible within the
empty socket for the third molar which is most likely related to infection or possible mandibular
lesion. The lung biopsy confirmed squamous cell carcinoma with lung primary. Further
pathological study of the tumor cells revealed positive immunostains for P63, CK5/6 and
weakly/moderately positive for TTF-1, negative for Napsin A and p16, consistent with squamous
cell carcinoma of lung primary. Positive controls for IHC stains and negative tissue elements
were both evaluated and are adequate for diagnosis. BM also had a pulmonary function test
(PFT) to evaluate her baseline lung functions.
Radiation Oncologist Recommendations: Since BM did not want surgical resection of the lung
nodule, she was then referred from thoracic/foregut team to the radiation oncology department
for radiation therapy. On the initial consultation, the radiation oncologist considered BM as a
good candidate for radiation treatment. After evaluating her health history in medical records,
pathology and multiple diagnostic studies, the radiation oncologist recommended stereostactic
body radiotherapy (SBRT) photon beam treatment to her left upper lung lobe for curative
purpose. SBRT is a radiotherapy procedure for treating any tumors outside of brain with high
dose per fraction (6 to 30 cGy) for five or fewer fractions.1 As an alternative treatment of surgery
for BMs lung tumor, SBRT could deliver conformal, accurate dose to the tumor while
minimizing damage to surrounding organs at risk (OAR). The treatment plan and the side effects
of radiation therapy were well communicated with BM. BM accepted the treatment plan and
signed the consents for the following simulation and radiation therapy.
The Plan: Since BM had decided to go through the radiation therapy, an intensity-modulated
radiotherapy (IMRT) technique for lung SBRT was decided as the radiation treatment plan.
IMRT is a radiation therapy technique to treat tumors by delivering nonuniform intensity dose

from any given position of the defined beam to the tumor while sparing the surrounding normal
tissues.1 About 7-10 days prior to the treatment, a simulation with CT scan, immobilization, and
markers was needed to prepare for the treatment planning. The total prescribed dose to her left
upper lung lobe was 60 Gray (Gy) at 12 Gy per fraction for 5 fractions. BM would come for the
radiation once daily for 5 days. Since her previous radiation therapy treatment site was not
overlapped with current planned treatment site, there was no complication for her previous
therapy and current plan. Skin care, diet, activity, medications, blood work were all addressed
prior to the radiation and after every treatment.
Patient Setup/Immobilization: On March 8, 2016, BM was simulated with 4-D computed
tomography (4DCT) reparation gating scan in the CT simulation room. 4DCT is a technique to
manage tumor motion by recording a series of CT images corresponding to10 desired phases of
the respiratory cycle.1 Prior to the simulation, BM was communicated with the simulation
procedure with expiration breath hold training, identification photos, positioning,
immobilization, measurement, markings and tattoos. She was positioned on the semi-deflated
Vac-Lok bag with wing board on the couch in the supine position. A large triangle sponge knee
lock was placed under knees for support and back rest. The radiation therapists aligned her on the
couch by using three lasers: one on the ceiling and two from each side of the walls. Seven
ExacTrac body markers over anterior chest were placed to localize the tumor and isocenter. After
she was situated on the couch, she was directed to hold the handles of wing board with arm up
above head. The radiation therapist (RT) then molded the bag around her anatomical body
contours. She was trained to hold breath for 10 seconds at the end of each regular breath circle
with cues of breathing in, breathing out and hold from interphone during scan. BM was very
anxious during the simulation and took longer time to complete the simulation. Finally a series of
CT images with 4DCT datasets for treatment planning were successfully collected and
transferred into the treatment planning system. After the scan, BM received tattoos on 7
ExaxTrac markers and three body leveling markers (one on each side of chest and one on the
anterior chest skin surface). Patient setup and immobilization photos were attached (see Figure1).
Anatomical Contouring: After the simulation, the CT images were exported and registered in
Varian Eclipse radiation treatment planning system for contouring and planning. The medical
dosimetrist then imported the images and contoured the left lung and other organs at risk (OAR)
including left lung, esophagus, great vessels, ipsilateral brachial plexus, laryngeal hyoid cricoid,

skin, spinal cord, and trachea carina. Four rings surrounding the planning target volume (PTV)
were also created for better dose distribution to tumor center and dose constrains in the OAR.
After then, the dosimetrist renamed and prepared the images for the radiation oncologist to draw
the gross tumor volume (GTV) and PTV volumes.
Beam Isocenter/Arrangement: The isocenter of the treatment plan was placed in the center of
PTV as a reference point of the treatment plan. Based on the volume of the treatment target and
the reference point, the medical dosimetrist created three arcs from different angles to deliver the
prescription dose directly to the tumor in left upper lobe (Figure 2-6). With the consideration of
time and radiation tolerance in ORA, the dosimetrist preferred volume modulated arc therapy
(VMAT) to deliver the dose through a Linac linear accelerator with different gantry rotation in a
358-degree. VMAT, also known as RapidArc, is a preferable technique superior to IMRT for
NSCLC with SBRT in terms of conformity, sparing of OAR, and treatment time.2 Three partial
arcs were created by beam one counterclockwise (CCW) from179.9 degree to 100 degree, beam
two clockwise (CW) from 340 degree to 179.9 degree, and beam three CCW from 90 degree to
10 degree (Figure 9-11). Beams were weighted differently to create a hot spot in the tumor area.
The ipsilateral brachial plexus was highly taken into account in the planning of dose intensity,
beam arrangement and weight due to the close distance to the PTV. Source-axis distance (SAD)
isocentric setup technique was used. The couch was fixed during the treatment. Only the
collimator rotates from zero to 90 degrees to accomplish with the gantry rotation. Dynamic
multi-leaf collimator (MLC) blocking was used to deliver designated intensity dose to the target.
The treatment field size, the rotation speed of the gantry, the shape of the MLC, and the delivery
rate were all automatically determined by the algorithm in the treatment planning system.
Treatment Planning: The radiation oncologist wrote the prescription dose of total 60 Gray (Gy)
at 12 Gy per fraction for 5 fractions for SBRT planning with dose constrains in certain structures:
PTV was to be equal or less than 66 Gy, total lung (V20) was to be less than 10%, the maximum
absolute dose in avoidance structure (brachial plexus) was 30 Gy with the highest priority, the
maximum dose to spinal cord was not greater than 30 Gy, esophagus was not greater than 40 Gy,
and chest wall (V30 Gy) was no greater than 30 ml with the lowest priority. The objective of the
plan was to deliver 100% of prescription dose to 100% of target volume. The optimal goal is to
distribute the maximum radiation dose in PTV but constrain minimum dose to normal lung
tissues and OAR based on their radiation tolerance levels. VMAT technique was suitable to

achieve the goal. Accuros XB was used for dose calculation. By reviewing the result of
calculation and dose distribution in the accumulative dose volume histogram (DVH) (See figure
12 for the final DVH), the medical dosimetrist adjusted the dose constrains and priorities of each
structure to achieve the treatment goal of expected coverage of isodose to the GTV and PTV, the
hot and cold areas, the dose constrains in PTV.
Quality Assurance/Physics Check: After the treatment plan was approved by the radiation
oncologist, it was exported to the RadCalc system for a second monitor units (MUs) check. The
reference tolerance level in our department is within 5% or 3 MU difference for each beam in the
treatment plan. In this treatment plan, the percent difference for beam one, two, and three are
-2.0%, -2.7%, and 2.2% respectively. The point dose at isocenter was also calculated with a
result of 1.5 %. After then, the physicist performed quality assurance (QA) plan check by using
Varian EPID portal dosimetry software. BMs treatment plan was directly delivered on the Linac
linear accelerator. Her treatment plan passed the QA check with a result of average Gamma for
each arc within 3% or 3 mm. After all, BM was treated on time by the scheduled appointments.
Conclusion: The SBRT planning with VMAT and 4DCT respiratory gating techniques for the
treatment of NSCLC demonstrated efficient treatment with highly conformal and accurate dose
distribution to the tumor and minimum damages to surrounding normal tissues.2 However, the
accuracy requirement of tumor localization and dose delivery in SBRT with VMAT raised a few
difficulties during the process. One difficulty was the management of tumor motion through
4DCT which is one of the essential factors in success of SBRT with VMAT lung treatment. The
patients anxiety had to be well managed during simulation and each treatment to maintain a
daily reproducible management of tumor motion. Another difficulty was maintaining accurate
patient immobilization with daily setup. An ideal treatment plan must be feasible and
reproducible. Patients anxiety level and function of the day, the variation of setup by the
radiation therapists on the day, and the verification equipment all increased the challenges of
maintaining the accuracy of immobilization. Therefore, prior to the treatment, patient came to the
treatment room for a dry run for verification of the isocenter, body markers, and feasible setup
with gantry movement without colliding the treatment table and patients elbows. Other than
these, an image-guided radiotherapy (IGRT) with MV cone-beam CT (CBCT) was performed
prior to each treatment to verify the geometry and localization of the treatment target.1 The
biggest difficulty in the treatment planning was to spare the brachial plexus with dose tolerance

of no more than 3000 cGy from a quick fall off of 6000 cGy tumor center in a 0.32 mm distance.
In order to achieve this objective, the PTV was only covered about 65% by the prescribed dose.
However, the tumor bed GTV was 100% covered (Figure7). The evaluation of the dose
distribution and coverage can be viewed on dose volume histogram (DVH) in figure 12. Beam
weight, gantry degree, and arcs were carefully adjusted and recalculated with each change to
achieve the goal. According to Brock et al,3 the treatment planning times including dosimetrist
planning time, inverse-planning calculation time and dose calculation time is a drawback of
SBRT with VMAT besides its significant advantages. By following this case study, I gained a
whole picture of the radiation treatment planning process especially more understandings on
VMAT and SBRT techniques. This is a great learning opportunity for me as a medical dosimetry
student.
References:
1. Khan FM, Gibbons JP. The Physics of Radiation Therapy. 5th ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2014: 196-198.
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.2012;14(1):228-238.
http://dx.doi.org/10.1120/jacmp.v14i1.4110
3. Brock J, Bedford J, Pertridge M, McDonald F, Ashley S, McNair HA, Brada M.
Optimizing stereotactic body radiotherapy for non-small cell lung cancer with volumetric
intensity-modulated arc therapy-A planning study. Clinical Oncology. 2012 Feb;24(1):6875. http://dx.doi.org/10.1016/j.clon.2011.02.003

Figure 1. Patient position with body markers on a Vac-Lok bag and a wing board at CT
simulation.

Figure 2. Isocenter placement at the center of PTV on anteroposterior (AP) view and lateral
view.

Figure 3. Isocenter placement on axial view.

Figure 4. Axial view of absolute isocentric dose lines at isocenter point.

Figure 5. Frontal view of absolute dose distribution of the left upper lung demonstrating 100%
of the prescription (red).

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Figure 6. Relative dose distribution on sagittal view.

Figure 7. Absolute dose distribution demonstrating isodose lines of 100% of the prescription
(red), PTV (purple), GTV (dark blue), and 30 cGy (light blue) with respect of the most critical
organ brachial plexus (yellow).

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Figure 8. Color wash view of the absolute dose distribution with respect of brachial plexus.

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Figure 9. Axial view of arc one created by beam one 340-179.9 CW.

Figure 10. Axial view of arc two created by beam two 179.9-100 CCW.

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Figure 11. Axial view of Arc three created by beam three 90-10 CW.

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Figure 12. A Dose Volume Histogram (DVH) demonstrates the dose distribution in tumor bed
GTV (red), PTV (purple), and selected critical organs: right lung (blue), left lung (green), and
brachial plexus (yellow). Each curve indicates the quantitative absorbed dose in certain volumes
of the structure and dose distribution for the interested structure.1