Romanian Reports in Physics, Vol. 67, No. 3, P.

978–986, 2015

VOLUMETRIC-MODULATED ARC THERAPY

VS. 3D-CONFORMAL RADIOTHERAPY FOR BREAST CANCER

D. ADAM1, 2, M.D. SUDITU1, 2, R. POPA1, 2, V. CIOCALTEI2

1
Faculty of Physics, University of Bucharest
2
Amethyst Radiology Therapeutic Center, Bucharest
Email address: [email protected]
Received June 26, 2013

Abstract. The treatment of breast cancer involves a multi-disciplinary approach with

radiation therapy playing a key role. Along the years different techniques were used
beginning with conventional tangential fields 2D, 3D conformal using multi leaf
collimator (MLC), and the newest technique VMAT (volumetric radiation therapy).
The aim of this study is to describe and compare two different modern planning
techniques for breast cancer: conformational technique compared to VMAT
technique. A set of ten patient computer tomographic (CT) images were selected for
treatment planning. The CT images were acquired using Brilliance Big Bore 120 CT
scanner and imported in Pinnacle3, version 9.2, system planning. The physician has
contoured the clinical target volume (CTV), which include the whole volume of the
breast. Dose prescription was 50 Gy to the average of the planning target volume
(PTV). PTV coverage and homogeneity were comparable for all techniques. After the
evaluation of the planning, it was observed that for VMAT technique as compared to
3D CRT it was obtained an important reducing dose to organs at risk (OAR) and to
contralateral breast. The PTV coverage was better than 95 % of prescribed dose for
95 % of target volume. A volume smaller than 5 % received less than 105 % of
prescribed dose for VMAT, for 3D CRT 95 % of target volume received 92 % of
prescribed dose and regarding the maximum dose more than 10% of PTV volume
received 105 % of prescribed dose. The volume of the ipsilateral lung receiving 20
Gy was 19 % for VMAT and 24 % for 3D-CRT. VMAT is considered the best
treatment option for patients with breast cancer.
Key words: VMAT, 3D CRT, breast cancer.

1. INTRODUCTION

An increase in the incidence of breast cancer in women aged less than 40

years has been reported in recent years. Increased incidence could be partly
explained by subtle detection biases, but the role of other risk factors cannot be
ruled out. After increasing for more than 2 decades, female breast cancer incidence
rates began decreasing in 2000, then dropped by about 7 % from 2002 to 2003.
This large decrease was thought to be due to the decline in use of hormone therapy
2 Volumetric-modulated arc therapy vs. 3D-conformal radiotherapy 979

after menopause that occurred after the results of the Women's Health Initiative
were published in 2002. This study linked the use of hormone therapy to an
increased risk of breast cancer and heart diseases. Incidence rates have been stable
in recent years [1]. Breast cancer is the second leading cause of cancer death in
women, being exceeded only by lung cancer. The chance that breast cancer will be
responsible for a woman death is about 1 in 36 (about 3 %). Death rates from
breast cancer have been declining since 1989, with larger decreases in women
younger than 50. These decreases are believed to be the result of earlier detection
through screening and increased awareness, as well as to an improved treatment.
Radiation therapy plays a major role in the management of breast cancer. Its place
and modalities for treatment have evolved over recent decades. In concert with the
new developments, there were significant improvements in radiotherapy techniques
in order to achieve more conformal radiotherapy with a good distribution on PTV
and a low dose to organ at risk. In the last years, the radiotherapy has progressed
from 2D conformal [2] to commonly used 3D conformal techniques and in the last
two years, volumetric modulated arc therapy (VMAT) [2].

2. MATERIAL AND METHODS

Treatment planning. To perform the treatment plan a set of CT imaging was

used. The patient was scanned using the Philips Brilliance Big Bore CT simulator.
The imagines were acquired using 5 mm slice thickness, containing 512×512 pixels
in each slice, with the dimensions of 0.9375×0.9375×2.5 mm3.
Structure definition. The gross tumor volume (GTV) covered the visible
primary tumor and the lymph nodes with macroscopic invasions. The clinical target
volume (CTV) contains the GTV with at least a 1 cm margin, which represent the
microscopic spread of disease. The planning target volume (PTV) included the
CTV with 5 mm extensions in all dimensions with the avoided of skin-3 mm
structure, to account for patient setup error and motion uncertainties. The volume
of PTV was 938.41 cm3. The prescribed dose was 50 Gy to the PTV, 2
Gy/fractionation in 25 fractionations. For organ at risk the following structures
were contoured: right and left lungs, esophagus, spinal cord, larynx, heart,
contralateral breast. For VMAT optimization the following helping structures were
created: normal tissue (skin ovoid interior PTV + 2 cm), and for influence the
shape and position of the dose gradient the PTV ring structure (0.5 cm uniform
margin). The contours of organ at risk and the PTV are available in Fig. 1. VMAT
plan and 3D CRT were performed by Pinnacle Treatment System (versions 9.4),
from Philips.
980 D. Adam et al. 3

Fig. 1 – The main organ at risk contoured by the physician for breast cancer treatment planning: right
lung, left lung, right breast and heart. The PTV (planning target volume) was created
by the physicists.

3D CRT PLAN. 3D CRT radiotherapy consisted of 4 tangential static fields.

To improve the homogeneity of dose in target volume (in order to reduce de maxim
dose) the filed in technique is used. The tangential fields used were internal
tangent, 1o at 310o gantry angles and external tangent, 1o at 130o gantry angles. The
fields have the following relative weight: internal tangent: 1 with the weight factor
50 %; internal tangent 2, with the weight factor 1.8 %; external tangent 1, with the
weight factor 46.4 %; external tangent 2, with the weight factor 1.8 %. The fields
were shaped with multi-leaf collimators on beam’s-eye-view, as it is shown in
Fig. 2. For the computations of the beams Collapse Cone Convolution algorithm
was used. After the beams were computed a total number of 228.8 monitors units
were calculated as follow.
VMAT (Volumetric Modulated Arc Therapy). VMAT plan consist of 2 arc
fields with the table at 0 degree with the start angle at 310o and the end angle at
150o, and the second arc in counterclockwise starting from 150 gantry degrees and
with the end point at 310 gantry degrees. All the arcs shared the same isocenter.
The SmartArc inverse planning optimizations algorithm was used. Coarse
segments around the arc are generated with an equal separation of 24°. The fluence
maps are converted to MLC segments for each beam orientation using the sliding-
window conversion algorithm. The segments were redistributed around the arc
length as it can be seen in Fig. 3, and linearly interpolated segments were added to
4 Volumetric-modulated arc therapy vs. 3D-conformal radiotherapy 981

reach final fine arc spacing. Segment-weight optimization was also performed on
the final segments [3].

External Tangent

Internal Tangent
Fig. 2 – The shaped fields with multi-leaf collimators on beam’s-eye-view,
used for 3D CRT planning.
982 D. Adam et al. 5

Fig. 3 – A MLC segments shapes from the control points of VMAT treatment planning.

The obtained plan has the following characteristics: the maximum delivery
time was set between 50 s and 80 s, and the estimated obtained delivery time was
20–83 s, the constrain leaf motion was set at 0.46 cm/deg. The conversion
constrain are: 4 cm2 minimum segment area, 2 minimum segment monitor units,
2 cm as the minimum overlap distance, and 4 cm as a maximum overlap distance.
In Fig. 3, it can be seen how these segments are distributed using VMAT technique
comparing with fields obtained from 3D CRT. According to the Radiation
Therapy Oncology Guides 0225, the planning objectives for PTV was at a
minimum dose greater than 95 %, and no more than 5% of PTV volume received
more than 105 % of the prescribed dose. The structural constraints used in this
study were represented in Table 1.
The 3D CRT and VMAT plan were created using the same 6 MeV photon
beams commissioned for an Elekta Synergy linac equipped with an 80-leaf 1 cm
multileaf collimator (MLC) (40 leaf pairs, maximum leaf speed of 2.0 cm/s), upper
jaws, and backup jaws covering a full area of 40×40 cm2 .
6 Volumetric-modulated arc therapy vs. 3D-conformal radiotherapy 983

Table 1
The Objectives for VMAT planning treatment which includes the regions of interest (ROI),
the type of constrains and the target that must be achieved. EUD = equivalent uniform dose

ROI TYPE TARGET(cGy)

PTV breast Uniform dose 5000
PTV breast Maxim dose 5150
PTV breast Minim dose 4950
PTV ring Maxim dose 4750
Left lung Maxim EUD 1250
Heart Maxim EUD 750
Spine Maxim dose 500
Normal tissue Maxim dose 2500

Contralateral breast Maxim dose 500

Dose-volume histogram plots were used to provide quantitative comparisons

between the VMAT and 3D CRT treatment plans. The resolution of the dose
calculation grid is 0.4 cm in all the directions (lateral, anterior-posterior and
superior-inferior). All data were based on the mean DVHs (dose volume
histograms) obtained from with a bin size resolution of 0.01 Gy. Organ-specific
individual DVH values were calculated. The uncertainties of these values were
reported as one standard deviation. The evaluation of the parameters for PTV
included: conformity index (CI) and homogeneity index (HI) [4]
VRI
Conformity Index RTOG = , (1)
TV
where VRI it is the reference isodose volume and TV is target volume.
A conformity index equal to 1 corresponds to an ideal conformation. A conformity
index greater than 1 indicates that the irradiated volume is greater than the target
volume and includes healthy tissues. If the conformity index is less than 1, the
target volume is only partially irradiated. According to RTOG guidelines, ranges of
conformity index values have been defined to determine the quality of con-
formation, because a value of 1 is rarely obtained. If the conformity index is situated
between 1 and 2, treatment is considered to comply with the treatment plan [5]
I max
Homogeneity index RTOG = , (2)
RI
where Imax is the maximum isodose in the target and RI is the reference isodose.
984 D. Adam et al. 7

If the “homogeneity index” treatment is ≤ 2, it is considered to comply with

the protocol. If this index varies between 2 and 2.5, the protocol violation is
considered to be minor, but when the index exceeds 2.5, the protocol violation is
considered to be major, but may nevertheless be considered to be acceptable. Dose
distributions obtained for VMAT and 3D CRT are represented in Fig. 4.

B
Fig. 4 – Dose distributions for 3D CRT (3D conformal) in figure A and for VMAT
(volumetric modulating arc therapy) in figure B. For 3D CRT the isodose lines are close to the left lung.
8 Volumetric-modulated arc therapy vs. 3D-conformal radiotherapy 985

3. RESULTS AND DISCUSSIONS

Dose to PTV. Regarding the coverage of V95%, it was obtained only 85 % of

the prescribe dose. The main problem in 3D CRT technique was the evaluation of
V107%, for which it was obtained a value of 22%, and for V105% a value of 30 % of
prescribe dose. For VMAT the coverage for V95% was 95.5 % of prescribe dose and
for V105% it was obtained a value of 4%. Conformation number reached a maximum
value of 0.66 for 3D CRT and 0.88 for VMAT. Homogeneity Index values for 3D
CRT was HI = 0.06, lower than in VMAT for witch it was obtained the value,
HI = 1.05.
Table 2
Parameters used for the evaluations of the PTV obtained for the treatment plan in cases
of the two techniques, 3D CRT and VMAT. ROI = region of interest
ROI 3D CRT VMAT
PTV
D95 % 85 % 95.40 %
D105 % 30 % 4.00 %
D107 % 22 % 1.87 %
Heart
Dmean 13 Gy 7.00 Gy
Dmax 51 Gy 38.00 Gy
Left lung
V20 24 % 19.00 %
Dmean 12 Gy 10.00 Gy
Contralateral breast
V10 Gy 1% 0%
Dmean 3 Gy 0.40 Gy
Normal tissue
Dmean 4 Gy 1.32 Gy

Dose to organ at risk. As it can be seen in Table 2, the value obtain for 3D
CRT technique are higher than the value for VMAT. The mean dose for heart is 13
Gy for conformal plan and 7 Gy for VMAT. The problems occur when maximum
dose for heart is evaluated, the value of 51 Gy being considerable high. Cardiac
toxicity after breast radiation therapy is the most reported radiation induced
complication. The most frequent clinical complications are pericarditis congestive
heart failure and heart attack. Chemotherapy plus radiotherapy increases the risk
factor that these problems to appear. Total dose delivered to the planned target
volume (PTV), the dose per fraction and the irradiated volume were correlated with
the risk of cardiotoxicity. Volume of heart receiving 35 Gy must be less than 30 %.
An important organ on the evaluation is the contralateral breast, because a high
dose could determinate a secondary cancer.
In this study we compared the maximum dose received by the main organ at
risk: for 3D CRT the maximum dose received by breast is 51 Gy compared with
VMAT where the maximum dose it is only 38 Gy. For left lung 20 Gy according
986 D. Adam et al. 9

with RTOG has to be less than 20 % of prescribe dose. This objective is reached
for VMAT plan and not for conformational one. Regarding dose received by
normal tissue the mean value obtained in 3D CRT plan is three times higher than
the dose obtained in VMAT plan. Over the years this could influence the health of
the patients. The dose being high for the organ at risk, will increase the risk of
appearing of secondary cancer. The result of this study confirms the advantage of
VMAT compared to 3D-CRT for breast cancer. It also confirms the additional gain
in dose distribution and delivery time, which can be achieved by VMAT. Planning
times it is longer for VMAT, which is however not considered a drawback
especially because dose to organ at risk is lower [6].

4. CONCLUSIONS

VMAT combines the advantages of good target coverage and homogeneity,

reduction of high-dose volumes in organ at risk. The dosimetric advantages of this
technique are used for reducing the risk of late radiation-induced toxicity related to
low-to-moderate doses in critical organs. VMAT technique is therefore considered
the best treatment option for breast cancer.
Acknowledgements. This paper is supported by the Sectoral Operational Programme Human
Resources Development (SOP HRD), financed from European Social Fund and by the Romanian
Government under the contract number SOP HRD/107/1.5/S/82514.

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