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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

ABSTRACT
The goal of this study was to determine if there was a difference in the percentage of lung
volume receiving a dose of 5Gy or more during IMRT or VMAT treatment planning. These
treatment techniques are relatively new to the industry. Determining how dose received by
critical organs may alter with these advancements is important in discovering what damages to
these organs may occur over time. Patients with centrally located tumors and PTV between 100-
1500cc were selected for this research study. They were positioned during their CT simulation in
the supine head first position. This was completed to place an isocenter, and to begin planning
treatments. Each patient had an IMRT treatment plan and a VMAT treatment plan created for
comparison purposes. The goal of the medical dosimetrist was to create a plan using both
methods that met spinal cord, lung, esophagus and heart constraints while maintaining PTV
coverage. A paired t-test was used to determine if there was a significant difference between the
planning techniques. The t-scores for the PTV coverage, lung V5 dose, lung V20 dose, lung V30
dose were 1.1, 3.02, 2.42, and 2.01, respectively. The t-score for PTV coverage and lung V30
were statistically insignificant meaning that PTV coverage for both planning techniques and the
percentage of lung volume receiving 30Gy or more was similar. The t-score for the lung V5 dose
and lung V20 dose was statistically significant, meaning there was an increase in the volume of
lung receiving 5Gy or higher and 20Gy or higher when using VMAT instead of IMRT. The
results of this study determined that both IMRT and VMAT planning are both viable techniques
to use when creating lung treatment plans. The OAR doses were kept below their constraints.
The IMRT planning technique was able to obtain similar PTV coverage when compared to the
VMAT planning technique but IMRT was able to maintain lower lung V5 and lung V20 dose.
Limitations of this study included the small sample size and lack of 3DCRT planning. Future
studies should include an increase in sample size, a comparison of IMRT, VMAT and 3DCRT
and a limitation on the number of beams utilized during IMRT planning.

Keywords: IMRT, VMAT, Lung V5 dose, centrally located lung tumors

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Introduction:
In the past 3D Conventional Radiation Therapy (3DCRT) planning was primarily used
for lung treatments and dose constraints were based on Dose Volume Histograms (DVHs) of
these plans.1 Through advancements in technology, Volumetric Modulated Arc Therapy
(VMAT) and Intensity Modulated Radiation Therapy (IMRT), are now being used for lung
treatment planning.2 The advanced treatment planning techniques have led to more entry points
for radiation dose by using multiple beams and continuous arcs. In retrospect, this has created a
risk for increasing the percentage of the lung volume receiving a dose of 5Gy or more (lung V5).3
The increased lung dose is a concern for patients because when the lung V5 dose increases, there
becomes a higher risk for radiation pneumonitis and other complications.3,4,5
Past studies have shown when comparing IMRT to VMAT, dynamic arc therapy
produces significantly greater low lung dose (V5) exposure as Planning Target Volume (PTV)
size increases compared to static IMRT.2,5 Previous research studies have proposed that V5 is not
predictive of radiation pneumonitis. However, studies have not indicated if V5 levels are higher
when dose is delivered with dynamic arcs. Graham et al. utilized the percentage of lung volume
receiving a dose of 20Gy or more (lung V20) to evaluate the risk of pneumonitis.1 Whilst looking
at this criterion alone may not be as predictive as previously thought, data now suggests that lung
V5 must be considered in addition to V20.2,3
The aim of the current research was to determine if lung dose is significantly higher in
VMAT treatments versus IMRT, as well as compare the two planning techniques to determine
which treatment technique provides better PTV coverage. This study demonstrates the
differences in VMAT and IMRT planning when treating centrally located lung tumors.
Materials and Methods:
Patients 
The patient data used for the treatment comparison was collected from three different
cancer centers. To be considered for the study, the patients had to be treated after 2015 and
prescribed to a certain dose range. All patients had centrally located lung tumors with a PTV
between 100-1500cc. The tumors ranged in the type of cancer and their progression. This meant
all stages and diagnoses were considered if they met the previous criteria. There were various
factors that would prevent patients from being part of the study. If a patient’s tumor was located
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laterally within the lung, instead of centrally, the patient would not be considered. Patients that
had any prior radiation treatments were considered ineligible for the study. Another important
factor was to be cognizant of the previous plan using V5 as an optimization parameter. This was
excluded from this study to prevent bias within the results. Controlling this within the study was
essential because if the V5 was used as an optimization parameter, the plan could not be used to
determine if IMRT or VMAT planning technique resulted in greater V5 dose.
Patient Setup
For treatment, all the patients were positioned in a similar fashion. Patients were setup in
the supine head first position during their Computed Tomography (CT) simulation (Figure 1).
The patient’s arms were placed over their heads using a T-Bar device. The T-Bar device was
utilized to remove the patient’s arms from radiation treatment area as well as lowering the dose
that the upper extremities would receive. A Vacuum-Lock bag was placed underneath the
patient’s chest and arms to provide stability and comfort. Lastly, an elastic band was placed
around their feet to help limit patient mobility during the scan and treatments by eliminating
fidgeting. This same positioning would be recreated for their radiation treatments daily. Once the
CT scan was performed, the isocenter was set by the radiation oncologist and medical
dosimetrist within the clinic. The radiation therapist then positioned the patient using positioning
lasers within the CT. This was done to align the patient at the isocenter that the physician had set.
The patient was then marked with three tattoos at the locations where the positioning lasers
intersected. These tattoos were used during treatment to ensure reproducibility and patient
alignment to the isocenter.
Contouring
After the CT simulation was performed, the patient's images were uploaded into either
Pinnacle or Eclipse treatment planning systems to be contoured by the radiation oncologists and
medical dosimetrists. The radiation oncologists contoured the gross tumor volume (GTV),
clinical target volume (CTV) and PTV. The GTV was created around the cancerous tissue
determined by imaging and the radiation oncologist. The GTV was then expanded 0.7 cm in all
directions to create the CTV. 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 Once the contours were completed, the plan was given to the medical
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dosimetrists to contour. The medical dosimetrists contoured the thoracic organs at risk (OAR)
following RTOG 0617 protocol to include spinal cord, lungs, esophagus, and heart (Table 1).6
Treatment Planning 
Treatment planning was performed using IMRT and VMAT techniques within the
Pinnacle or Eclipse treatment planning systems. Applying proper technique depended on the
tumor size, tumor location, OAR and dose-tolerance criteria. The medical dosimetrists used 6
megavoltage energy photon beams for both the IMRT and VMAT plans involving the centrally
located lung tumors. The prescriptions ranged between 45Gy-70Gy for treatments but was kept
consistent when re-planning using the different treatment technique for the current study.
IMRT treatments take more time because the patient and radiation therapists must wait
for the gantry to be setup at the appropriate beam angle. The medical dosimetrists used 5-9
beams for each IMRT plan (Figure 2).4 The beams were placed at angles to avoid the OAR,
specifically to avoid the spinal cord. IMRT improves dose conformity when compared to
standard three-dimensional treatments. However, a minor draw-back to this form of planning is
the lengthy delivery time.2
VMAT produces highly conformal dose distribution, improves the delivery efficiency by
reducing treatment time and produces accurate dosimetric calculations.2 The VMAT beams were
arranged as two partial arcs, two full arcs, three partial arcs or three full arcs with varying
collimator angles (Figure 3). The beams were planned with different rotational directions,
clockwise (CW) and counter clockwise (CCW). The arcs and collimator angles were chosen to
avoid OAR while maintaining the best coverage of the PTV.
To determine the constraints for the OAR used for planning and optimization, the
radiation oncologist referred to RTOG 0617 for creating the IMRT and VMAT treatment plans.
The plans would be created by optimizing to lung(s), spinal cord, esophagus, heart constraints,
while simultaneously optimizing to obtain PTV coverage (Table 1). Once an IMRT and a VMAT
plan was created for each patient, the plans would be compared to identify the differences.
Plan Comparisons 
Plan comparison for this portion of the research study, required comparing previous plans
using both IMRT and VMAT techniques. In order to achieve this, data was collected from each
patient case anonymously and recorded for analysis. Various factors were recorded such as,
percentage of lung volume receiving 30Gy (V30) or more, Lung V20, Lung V5, percentage of PTV
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coverage and objectives of normal organs at risk (ex. esophagus, heart, and spinal cord). These
values allowed comparison of plan quality between IMRT and VMAT.
To prevent bias of the data set, plans chosen for comparison purposes had to meet certain
criteria to be considered eligible for data collection. This criterion included remaining within a
certain range for the prescription dose, PTV volume (cc), PTV vertical length (cm), and lung
volume (cc). Data collection also involved compiling the data together at the end to calculate the
results statistically.
The main objective of this data collection was to create a coherent method to compare
which plan is the best when looking at various factors, in order to allow consistency among the
plans chosen.
Results:
Coverage of the PTV in VMAT plans (mean= 95.02, SD= 2.54) was not significantly
greater than IMRT plans (mean= 94.1, SD= 3.2) based on a 2-tailed test for paired samples (t13 =
1.1, P = .29). Lung V30 dose in VMAT plans (mean= 19.17, SD= 5.93) was not significantly
greater than IMRT plans (mean= 16.77, SD= 5.03) based on a 2-tailed test for paired samples (t13
= 2.01, P = .066). Lung V20 dose in VMAT plans (mean= 27, SD=6.29) was significantly greater
than IMRT plans (mean= 25.72, SD= 6.95) based on a 2-tailed test for paired samples (t13 = 2.42,
P = .031). Lung V5 dose in VMAT plans (mean= 9.57, SD=17.16) was significantly greater than
IMRT plans (mean= 63.5, SD= 14.73) based on a 2-tailed test for paired samples (t13 = 3.02, P =
.001).
Discussion
Coverage of the lung tumor PTV remained statistically similar when using IMRT versus
VMAT treatment planning techniques. For each patient, the plan was normalized to meet the
PTV coverage requirements. The difference between VMAT planning and IMRT planning, was
the number of gantry angles utilized by VMAT during its motion through the arc, while IMRT
was limited to the beam angles chosen by the medical dosimetrist. Both IMRT and VMAT
treatments were able to meet PTV coverage due to their multiple dose entry points leading to
conformality and adequate coverage.
The difference between the percentage of lung V30 dose for IMRT and VMAT was not
statistically significant. When looking at higher doses delivered to the lung, the differences
between treatment techniques became less noticeable. This was due to medical dosimetrists
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limiting the amount of dose received by the lung during optimization. Through this optimization,
both techniques were able to lower the lung V30 dose.
When comparing the two treatment strategies, the difference between the lung V5 dose
and lung V20 dose increased significantly when comparing VMAT to IMRT plans. When the
medical dosimetrists used VMAT as their planning strategy, the dose entered the patient
continuously while the gantry moved along the arc. This resulted in dose being delivered to the
patient’s body through more entry points when compared to IMRT treatment planning. With this
change in dose delivery, patients received higher amounts of low lung dose due to the increase in
access to the lungs during movement of the arcs and the resulting more dose entry points.
Therefore, the lung V5 dose and lung V20 for IMRT was lower than the lung V5 dose and lung
V20 dose for VMAT plans.
Conclusion:
Through advancements in technology, IMRT and VMAT planning are now being used to
perform lung treatments. With the introduction of these techniques, the difference of lung V5
dose needed more analysis due to its potential to cause pneumonitis. Patients with centrally
located lung tumors were selected and IMRT and VMAT plans were created to determine the
differences in PTV coverage, lung V5, lung V20, and lung V30 dose. When comparing IMRT and
VMAT treatment plans, there were differences found amongst both techniques. Planning with
IMRT and VMAT, resulted in similar PTV coverage and lung V30 dose. Using the VMAT
planning technique however, resulted in higher lung V5 dose and lung V20 dose in patients with
centrally located lung tumors. Both techniques were beneficial to the medical dosimetrists
because they were able to maintain coverage while limiting dose to critical structures due to
blocking and beam placement. The limitations for this study included the small sample size and
not including 3DCRT as one of the planning techniques for comparison.
For future studies, the number of beams used during IMRT should be limited to six to see
if there is more of a difference in the V5 lung dose in IMRT and VMAT treatments.4 Medical
dosimetrists should also look at IMRT planning versus 3DCRT and VMAT versus 3DCRT to see
how much the lung V5 dose has increased with planning technique advancements. Knowing the
amount of lung V5 dose a patient is receiving is important because increased low lung doses
could lead to future radiation damage.
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References
1. 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.
https://dx.doi.org/10.1016/S0360-3016(99)00183-2
2. Li Y, Wang J, Tan L, et al. Dosimetric comparison between IMRT and VMAT in irradiation
for peripheral and central lung cancer. Oncol Lett. 2018;15(3):3735-3745.
https://dx.doi.org/10.3892/ol.2018.7732
3. Aaron A, Czerminska M, Jänne P, et al. Fatal pneumonitis associated with intensity-
modulated radiation therapy for mesothelioma. Int J Radiat Oncol Biol Phys. 2006;65(3):640
– 645.
https://dx.doi.org/10.1016/j.ijrobp.2006.03.012
4. Helen H, Jauregui M, Zhang X, et al. Beam angle optimization and reduction for intensity-
modulated radiation therapy of non–small-cell lung cancers. Int J Radiat Oncol Biol Phys.
2006;65(2):561–572.
https://dx.doi.org/10.1016/j.ijrobp.2006.01.033
5. Lievens Y, Nulens A, Gaber MA, et al. Intensity-modulated radiotherapy for locally
advanced non-small-cell lung cancer: a dose-escalation planning study. Int J Radiat Oncol
Biol Phys. 2011;80(1):306-313.
https://dx.doi.org/10.1016/j.ijrobp.2010.06.025
6. Bradley J, Choy H, Komaki R, et al. RTOG 0617: A randomized phase III comparison of
standard-dose (60 Gy) versus high dose (74 Gy) conformal radiotherapy with concurrent and
consolidation carboplatin/paclitaxel +/- cetuximab (IND #103444) in patients with stage
IIIA/IIIB non-small cell lung cancer. Lancet Oncol. 2015(2):187-199.
https://dx.doi.org/10.1016/S1470-2045(14)71207-0
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Figures

Figure 1. Patient position during CT simulation. Patient was setup in the supine position with
both arms up and a vacuum-lock bag was placed underneath to provide stability and
comfort.
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Figure 2. The arrangement of the beams, for the 7-beam IMRT treatment technique, were
placed to avoid the spinal cord and produced dose conformity.
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Figure 3. An example of a 3-arc VMAT utilizing clockwise and counterclockwise motion to

produce a highly conformal dose distribution.
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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%