Received: 17 March 2018 | Revised: 27 June 2018 | Accepted: 3 July 2018

DOI: 10.1002/acm2.12422

RADIATION ONCOLOGY PHYSICS

A study of minimum segment width parameter on VMAT plan

quality, delivery accuracy, and efficiency for cervical cancer
using Monaco TPS

Yuanyuan Wang1 | Li Chen2 | Fengying Zhu3 | Wanjing Guo4 | Dandan Zhang2 |

Wenzhao Sun2

1
Department of Radiation Oncology, Hefei
Ion Medical Center, Hefei, China Abstract
2
State Key Laboratory of Oncology in Purpose: The purpose of this study was to study the influence of the minimum seg-
South China, Collaborative Innovation
ment width (MSW) on volumetric modulated arc therapy (VMAT) plan quality, deliv-
Center for Cancer Medicine, Sun Yat-sen
University Cancer Center, Guangzhou, ery accuracy, and efficiency for cervical cancer treatment.
China
Methods: Nineteen patients with cervical cancer were randomly selected to design
3
Shunde Hospital of Southern Medical
University, Shunde, China VMAT plans. Three VMAT plans were generated for each patient incorporating
4
Qingyuan People's Hospital, Qingyuan, MSWs of 0.5, 1.0, and 1.5 cm while other planning parameters remained constant
China
using the Monaco treatment planning system (TPS) with 6 MV X rays delivered from
Author to whom correspondence should be an Elekta Synergy linear accelerator. Plan quality and delivery efficiency were evalu-
addressed. Li Chen
ated based on dose‐volume histograms (DVHs), control points, monitor units (MUs),
E-mail: [email protected];
Telephone: +8602087343710 dosimetric measurement verification results, and plan delivery time.
Results: Except for the small difference in target dose coverage and maximum dose,
there were no statistically significant differences between the other dosimetric param-
eters in the planning target volumes. The 1.0 and 1.5 cm MSW plans showed lower
maximum doses to the spinal cord than the 0.5 cm plan; doses to other organs at risks
were similar regardless of MSWs. The mean reductions of total MUs when compared
with the 0.5 cm plan were 14.5 ± 6.1% and 20.9 ± 7.9% for MSWs of 1.0 and 1.5 cm,
respectively. The calculated gamma indices using the 3% and 3 mm criteria were
96.2 ± 0.6%, 97.0 ± 0.6%, and 97.6 ± 0.6% for the 0.5, 1.0 and 1.5 cm MSW plans,
respectively. The plan delivery times decreased with increasing MSWs (p < 0.05).
Conclusion: Increasing the MSW allows for improved plan delivery accuracy and
efficiency without significantly affecting the VMAT plan quality. MSWs of 1.0 and
1.5 cm improved the plan quality, delivery accuracy, and efficiency for cervical
VMAT radiation therapy.

PACS
87.55.de

KEY WORDS
cervical cancer, delivery time, Minimum segment width, plan quality, VMAT

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This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2018 The Authors. Journal of Applied Clinical Medical Physics published by Wiley Periodicals, Inc. on behalf of American Association of Physicists in Medicine.

J Appl Clin Med Phys 2018; xx:x: 1–7 wileyonlinelibrary.com/journal/jacmp | 1

2 | WANG ET AL.

1 | INTRODUCTION
2 | MATERIALS AND METHODS
Over the last decade, volumetric modulated arc therapy (VMAT)
2.A | Patient selection
has been explored and implemented to treat a variety of cancers
including in the prostate, head and neck, lung, and spine.1–4 Nineteen patients with cervical cancer aged between 38 and 78 yr
VMAT is a dynamic treatment technique in which the radiation (average 52.6 yr) who underwent VMAT at our hospital between June
dose rates, gantry speeds, and movements of the multi‐leaf colli- 2017 and October 2017 were enrolled in this study. This study was
5
mator and jaws are simultaneously varied while the beam is on. approved by the Ethical Commission of our cancer center. Because
VMAT enables greater dose conformity to target tissues, and this was not a treatment‐based study, our institutional review board
spares more of the normal tissue than traditional three‐dimen- waived the need for written informed consent from the participants.
sional conformal radiation therapy (3D‐CRT) and intensity‐modu- The patient information was anonymized and de‐identified to protect
6–8
lated radiation therapy (IMRT). Generally, VMAT planning patient confidentiality.
involves a two‐step optimization procedure: First, ideal fluence
maps are optimized and calculated according to an optimization T A B L E 1 The cost functions of VMAT planning for cervical cancer.

algorithm; next, the arc sequencer algorithm converts these flu- ROIs Cost function Parameter Iso constraint

ence maps to arc delivery maps while optimizing the multi‐leaf PTV60 Target penalty 95% 60 Gy

collimator shape sequence to serial segments (control points). The Underdose DVH 60 Gy 98%

minimum segment width (MSW) parameter takes an important role Quadratic overdose 63 Gy 20

in the creation of the shapes and sizes of these segments. When PTV45 Target penalty 95% 45 Gy

designing VMAT plans to treat cervical cancer, optimization often Underdose DVH 45 Gy 96%

results in some long and narrow segments that may have a Quadratic Overdose 48 Gy 50

notable impact on plan delivery, and can sometimes lead to a low Spinal cord Maximum dose NA 40 Gy

verification passing rate and even an interruption. The impact of Rectum Quadratic overdose 45 Gy 40

VMAT planning parameters, such as small monitor unit (MU) per Bladder Quadratic overdose 45 Gy 60

segment, dose rate, and control point spacing, on plan quality Kidney‐L Serial k = 12 18 Gy

have been evaluated for a Pinnacle3 treatment planning system Kidney‐R Serial k = 12 18 Gy
9,10 Femoral head‐L Maximum dose NA 48 Gy
(TPS) using the Elekta Synergy/Varian Trilogy linear accelerator.
However, there have been no reports regarding MSW optimization Femoral head‐R Maximum dose NA 48 Gy

in terms of VMAT plan quality, delivery, accuracy, and efficiency. Body Quadratic overdose 45 Gy 20

The purpose of this study was to explore the influence of the Quadratic overdose 30 Gy 120

MSW parameter on the quality and delivery accuracy of VMAT Maximum dose Shrink 0.9 cm 45 Gy

plans for cervical cancer to provide a useful reference for clinical ROI, region of interest; PTV, planning target volume; DVH, dose‐volume
treatment planning. histogram.

F I G . 1 . The shapes of the planning

target volumes (a–c) and a typical segment
(d) for a cervical volumetric modulated arc
therapy plan. The red contour denotes the
PTV60 and the blue contour denotes the
PTV45 in (a), (b), and (c). d: Digitally
reconstructed radiography for a typical
segment from the beam's eye view
(gantry = 112°). The green outline
represents the shape of the segment.
WANG ET AL. | 3

T A B L E 2 PTV dosimetric results of the VMAT plans used to treat 19 cervical cancer patients devised using three different MSWs.
PTV Parameter 0.5 cm MSW 1.0 cm MSW 1.5 cm MSW p1 p2 p3
PTV60 TC (%) 99.5 ± 0.13 99.4 ± 0.16 99.18 ± 0.22 0.02 0.01a 0.04
Dmean (Gy) 62.7 ± 0.06 62.6 ± 0.05 62.73 ± 0.05 0.07 0.38 0.08
Dmax (Gy) 65.4 ± 0.23 65.2 ± 0.19 65.52 ± 0.26 0.01a 0.68 0.07
CI 0.44 ± 0.02 0.51 ± 0.06 0.47 ± 0.02 0.27 0.98 0.27
HI 1.04 ± 0.00 1.04 ± 0.00 1.04 ± 0.00 0.33 0.86 0.87
PTV45 TC (%) 99.45 ± 0.12 99.28 ± 0.13 98.88 ± 0.16 0.02 0.01a 0.01a
Dmean (Gy) 49.76 ± 0.39 49.72 ± 0.39 49.82 ± 0.41 0.26 0.16 0.02
Dmax (Gy) 65.66 ± 0.28 65.37 ± 0.23 65.51 ± 0.22 0.01 a
0.782 0.11
CI 0.75 ± 0.01 0.75 ± 0.01 0.75 ± 0.01 0.37 0.54 0.92
HI 1.27 ± 0.02 1.26 ± 0.02 1.28 ± 0.02 0.02 0.01 a
0.00a

p1, p‐value comparing 0.5 cm and 1.0 cm MSW plans; p2, p‐value comparing 0.5 and 1.5 cm MSW plans; p3, p‐value comparing 1.0 and 1.5 cm MSW
plans. PTV, planning target volume; VMAT, volumetric modulated arc therapy; MSW, minimum segment width; TC, target coverage; Dmean, mean dose;
Dmax, maximum dose; CI, conformity index; HI, heterogeneity index.
a
statistically significant according to Bonferroni correction.

F I G . 2 . The dose‐volume histograms of

three volumetric modulated arc therapy
plans with different minimum segment
widths (MSWs) for a typical cervical
cancer.

Elekta Synergy linear accelerator with X ray beam energy (6 MV). Each
2.B | Simulation and contouring
case was planned with a single arc of 360° rotating clockwise from
All patients were immobilized with a vacuum bag system with a 181° to 179°. The collimator angle for each patient was fixed to 0° dur-
supine position, and were then scanned using a Philips computed ing gantry rotation, based on the patient's anatomy. The statistical
tomography (CT) simulator with a slice thickness of 3 mm. The uncertainty of the MC algorithm was 3% per control point, and the
reconstructed CT images were transmitted to Monaco 5.11 TPS. final dose was calculated with a calculation grid resolution of 3 mm.
Gross tumor volume (GTV) and clinical tumor volume (CTV) were The maximum number of control points was 150 for each plan. Three
delineated on CT images by an experienced radiation oncologist VMAT plans, 0.5 cm MSW, 1.0 cm MSW, and 1.5 cm MSW, were gen-
according to the institutional protocol. A contour expansion was erated with MSWs of 0.5, 1.0, and 1.5 cm, respectively, while other
applied to the GTV and CTV to delineate a planning target volume parameters and cost functions remained unchanged. The prescription
(PTV) that would receive 60 Gy (PTV60) and 45 Gy (PTV45). PTV60 dose was the dose to 98% of the PTV60 (D98%) that received at least
was derived from the GTV with involved lymph nodes plus a uniform 60 Gy in 23 fractions. The cost functions are displayed in Table 1.
5 mm margin, while the PTV45 was generated from the CTV plus a
uniform 6–8 mm margin (Fig. 1). The bladder, rectum, spinal cord,
2.D | Plan evaluation
kidneys, and femoral heads were delineated as organs at risk (OARs).
The different MSW cervical plans were compared in terms of dosi-
metric indices such as the homogeneity index (HI), conformity index
2.C | Treatment planning
(CI), maximum dose of target volume, target coverage (TC), MUs,
For all patients, VMAT plans were designed using the Monaco TPS via control points, and the DVH parameters concerning OARs. The TC
the Monte Carlo (MC) algorithm, and plans were delivered using the and HI were determined as follows:
4 | WANG ET AL.

F I G . 3 . The homogeneity index (HI) and conformity index (CI) of the planning target volumes (PTVs) for 19 cervical volumetric modulated
arc therapy plans using three different minimum segment widths (MSWs). a: HI of PTV60; b: CI of PTV60; c: HI of PTV45; d: CI of PTV45.

T A B L E 3 Doses to the OARs of the VMAT plans with three different MSWs for 19 cervical cancer patients.
OAR Parameter 0.5 cm MSW 1.0 cm MSW 1.5 cm MSW p1 p2 p3
Spinal cord Dmax (Gy) 25.18 ± 3.89 24.28 ± 3.79 23.13 ± 3.59 0.08 0.01 a
0.02
Rectum V30 Gy (%) 8.96 ± 2.25 8.43 ± 2.19 9.01 ± 2.20 0.15 0.55 0.06
Bladder V30 Gy (%) 12.49 ± 3.16 11.73 ± 2.79 12.21 ± 2.97 0.12 0.83 0.15
Kidney‐L V45 Gy (%) 62.10 ± 5.40 63.53 ± 5.44 61.51 ± 5.58 0.28 0.92 0.16
Kidney‐R V45 Gy (%) 48.38 ± 4.10 47.62 ± 4.04 48.52 ± 4.24 0.42 0.74 0.66
Femoral head‐L V30 Gy (%) 38.91 ± 2.63 39.32 ± 2.75 41.68 ± 3.56 0.75 0.14 0.07
Femoral head‐R V30 Gy (%) 37.56 ± 3.73 40.77 ± 3.91 39.87 ± 3.98 0.06 0.36 0.67

p1, p‐value comparing 0.5 and 1.0 cm MSW plans; p2, p‐value comparing 0.5 and 1.5 cm MSW plans; p3, p‐value comparing 1.0 and 1.5 cm MSW plans.
VMAT, volumetric modulated arc therapy; OAR, organ‐at‐risk; MSW, minimum segment width; Dmax, maximum dose; Vx, percentage volume of region
of interest receiving at least X Gy.
a
statistically significant according to Bonferroni correction.

TCð%Þ ¼ ðTVPI =TVÞ  100 (1) The CI was calculated as below:

CI ¼ ðTVPI Þ2 =ðTV  VPI Þ (3)

HI ¼ D5% =D95% (2)
where VPI represents the total volume receiving the prescription
where TVPI represents the target volume receiving the prescription dose (60 Gy or 45 Gy); the closer the CI is to 1, the more conformal
dose, TV represents the total target volume. D5% is the minimum is the target dose distribution.
dose received by 5% of the PTV according to the DVH (indicating Absolute dose distributions were measured using an Elekta
the maximum dose), and D95% is the minimum dose received by 95% iViewGT aSi electronic portal imaging device (EPID) detector. The
of the PTV (indicating the minimum dose). A lower HI represents EPID has a sensitive area that is 41 cm × 41 cm in size with an
better homogeneity. effective pixel size of 0.04 cm × 0.04 cm. Offset, gain, and pixel
WANG ET AL. | 5

corrections were performed for each image, and a time‐integrated between beam activation and deactivation) was measured simultane-
signal was obtained for every plan. The pixel values in the EPID ously for each plan.
images were reconstructed to dose values at a source to axis dis-
tance of 100 cm in the phantom.11 The measured and computed
2.E | Statistical analysis
doses were analyzed using RapiDose (Version 2.1, RayDose Inc.,
China) commercial software to analyze and calculate the gamma The paired t‐test followed by Bonferroni's correction was applied in
passing rate (GPR).12 The plan delivery time (PDT; ie, the interval the intergroup comparison for dosimetric parameters and measure-
ment results using the SPSS 19.0 software. A p-value <0.05 indi-
cated a statistically significant difference.

3 | RESULTS

3.A | Target doses

The target doses of the three VMAT plan groups are shown in
Table 2. The mean and maximum PTV60 and PTV45 doses were not
markedly different among the three plans. The target dose coverage
of the plan using an MSW of 0.5 cm was higher than that of the
plan using an MSW of 1.0 cm, which in turn was better than that of
the plan using an MSW of 1.5 cm. The DVH results using these
three plans in a typical patient with cervical cancer are shown in
Fig. 2. The maximum PTV60 and PTV45 doses of the plan using an
MSW of 1.5 cm were higher than those of the plans with MSWs of
0.5 and 1.0 cm.
F I G . 4 . Box and whisker histograms of the control points for the The CI and HI values for all treatment plans are shown in Fig. 3.
different minimum segment widths plans. The CI and HI for the PTV60 are similar among all three group plans

F I G . 5 . Monitor units for plans with

different minimum segment width (MSW).

T A B L E 4 Gamma passing rates and delivery times for plans with different minimum segment widths (MSWs).
Parameter 0.5 cm MSW 1.0 cm MSW 1.5 cm MSW p1 p2 p3
3% and 3 mm GPR 96.23 ± 0.59 97.00 ± 0.56 97.59 ± 0.59 <0.01a <0.01a <0.01a
2% and 2 mm GPR 85.35 ± 1.38 87.58 ± 1.27 89.28 ± 1.44 <0.01 a
<0.01 a
0.01a
PDT (min) 4.39 ± 0.12 4.23 ± 0.10 4.07 ± 0.11 0.01 a
<0.01 a
0.01a

p1, p‐value comparing 0.5 cm and 1.0 cm MSW plans; p2, p‐value comparing 0.5 cm and 1.5 cm MSW plans; p3: p‐value comparing 1.0 cm and 1.5 cm
MSW plans. MSW, minimum segment width; GPR, gamma passing rate; PDT, plan delivery time.
a
statistically significant according to Bonferroni correction.
6 | WANG ET AL.

(p > 0.05). As for the PTV45, the 1.0 cm MSW plan had a lower HI >94% when using the 3% DD and 3 mm DTA criteria, and >85%
than the 0.5 and 1.5 cm MSW plans. when using the 2% DD and 2 mm DTA criteria.13 This showed that
the measured dose was consistent with the calculated dose. The dose
measured when using a higher MSW showed better agreement with
3.B | OAR dose
the calculated dose from the TPS; this was expected given that the
OAR dose results are shown in Table 3. Except for the lower number of small fields decrease as the MSW increased, and dosimetric
maximum dose to the spinal cord when using the plan with the verification would therefore be relatively easier.
highest MSW, there were no significant differences between the In addition, the number of control points and MUs decreased as
three types of VMAT plans in terms of doses to the remaining the MSWs increased. When compared to the plan using a MSW of
OARs. 0.5 cm, the mean MU reductions in the plans using MSWs of 1.0
and 1.5 cm were 15.2% and 21.9%, respectively, while the total con-
trol points were decreased by 2.9% and 8.8%, respectively. Previous
3.C | Control points and MUs
studies showed that decreasing the MUs for treatment delivery
As the MSW value increased, the control points of the cervical can- reduces the constraint factor of the leaves’ trajectories, complexity
cer VMAT plan decreased; the mean number of control points for of intensity‐modulated radiation therapy plans, and treatment
the plans with MSWs of 0.5, 1.0 and 1.5 cm were 137, 133, and time.14–17 Hence, as the MSW increases and VMAT plan complexity
125, respectively (Fig. 4). Moreover, the MUs of the VMAT plan decreases, the therapeutic efficiency may improve as well. The aver-
decreased as the MSW increased (Fig. 5); the mean MUs for the age delivery times of the plans using MSWs of 1.0 and 1.5 cm were
plans with MSWs of 0.5, 1.0, and 1.5 cm were 889.1 ± 164.5, decreased by 9.6 and 19.2 s, respectively (a drop of approximately
754.3 ± 113.4, and 694.1 ± 88.8, respectively. 3.6% and 7.3%, respectively), compared to the plan with a MSW of
0.5 cm.

3.D | Dosimetric verification and plan delivery time

Comparison between the measured planar dose and TPS‐calculated 5 | CONCLUSION
dose was analyzed using the gamma passing criteria of a 2% dose
difference (DD) and a 2 mm distance to agreement (DTA), as well as Generally, VMAT plans of cervical cancer that are generated with
with passing criteria of a 3% DD and 3 mm DTA. Table 4 shows the smaller MSWs have not only increased target coverage and confor-
GPRs for the 0.5, 1.0, and 1.5 cm MSW plans. The GPR was highest mal index, but also lead to more control points and MUs that would
with the plan using a MSW of 1.5 cm and lowest in the plan using a produce lower GPRs and greater treatment delivery times. Our data
MSW of 0.5 cm. Table 4 also shows the plan delivery time from indicated that VMAT plans with MSWs of 1.0 cm show a clear
beam turn‐on to turn‐off for all 19 patients. As the MSW increased, advantage in terms of a trade‐off between plan quality and delivery
the control points and MUs of the VMAT plan decreased, as did the efficiency for cervical cancer, and can optimally meet the clinical
plan delivery time. requirements.

CONFLICTS OF INTEREST
4 | DISCUSSION
The authors declare no conflicts of interest.
Designing VMAT plans for treating cervical cancer produces a large
number of long, small, and irregular segments. MSW takes an impor- REFERENCES
tant role in the forming of optimized apertures. These segments
1. Pyshniak V, Fotina I, Zverava A, et al. Efficiency of biological versus
sometimes lead to low verification rate and even interruption during physical optimization for single arc VMAT for prostate and head and
delivery of VMAT plan in clinical works. As plan complexity can be neck cases. J Appl Clin Med Phys. 2014;15:4514.
reduced by increasing the MSW, we compared the qualities of three 2. Chan M, Wong M, Leung R, et al. Optimizing the prescription iso-
different cervical cancer VMAT plan optimization schemes that were dose level in stereotactic volumetric‐modulated arc radiotherapy of
lung lesions as a potential for dose de‐escalation. Radiat Oncol.
based on three different MSW values. Quality comparisons included
2018;13:24.
evaluating the HI, CI, TC, maximum doses, and mean doses to the 3. Middlebrook ND, Sutherland B, Kairn T. Optimization of the dosi-
PTV, as well as the dose‐volume index of the OARs, MUs, and con- metric leaf gap for use in planning VMAT treatments of spine SABR
trol points. VMAT plans generated with a MSW of 1.0 cm were cases. J Appl Clin Med Phys. 2017;18:133–139.
4. Zach L, Tsvang L, Alezra D, et al. Volumetric modulated arc therapy
found to have similar dose distributions as plans with MSWs of
for spine radiosurgery: superior treatment planning and delivery
0.5 cm. However, plans with MSWs of 1.5 cm were of slightly worse compared to static beam intensity modulated radiotherapy. Biomed
quality, although they still satisfied clinical requirements (Fig. 2). Res Int. 2016;2016:6805979.
The measured and computed doses were analyzed using an EPID 5. Yu CX, Tang G. Intensity‐modulated arc therapy: principles, technolo-
gies and clinical implementation. Phys Med Biol. 2011;56:R31–R54.
detector. All treatment plans showed good GPRs; the mean GPR was
WANG ET AL. | 7

6. Matuszak MM, Yan D, Grills I, Martinez A. Clinical applications of based on electronic portal imaging devices. Chin J Radiat Oncol.
volumetric modulated arc therapy. Int J Radiat Oncol Biol Phys. 2012;21:550–553.
2010;77:608–616. 12. Huang M, Huang D, Zhang J, et al. Preliminary study of clinical appli-
7. McGrath SD, Matuszak MM, Yan D, et al. Volumetric modulated arc cation on IMRT three‐dimensional dose verification‐based EPID sys-
therapy for delivery of hypofractionated stereotactic lung radiother- tem. J Appl Clin Med Phys. 2017;18:97–105.
apy: a dosimetric and treatment efficiency analysis. Radiother Oncol. 13. Ezzell GA, Burmeister JW, Dogan N, et al. IMRT commissioning: mul-
2010;95:153–157. tiple institution planning and dosimetry comparisons, a report from
8. Diot Q, Kavanagh B, Timmerman R, Miften M. Biological‐based opti- AAPM Task Group 119. Med Phys. 2009;36:5359–5373.
mization and volumetric modulated arc therapy delivery for stereo- 14. Coselmon MM, Moran JM, Radawski J, Fraass BA. Improving IMRT
tactic body radiation therapy. Med Phys. 2012;39:237–245. delivery efficiency using intensity limits during inverse planning. Med
9. Huang L, Zhuang T, Mastroianni A, et al. Impact of small Phys. 2005;32:1234–1245.
MU/segment and dose rate on delivery accuracy of volumetric‐ 15. Sun X, Xia P, Yu N. Effects of the intensity levels and beam map res-
modulated arc therapy (VMAT). J Appl Clin Med Phys. olutions on static IMRT plans. Med Phys. 2004;31:2402–2411.
2016;17:203–210. 16. Young KC, Matuszak MM, Moran JM, et al. Penalization of aperture
10. Yang K, Yan D, Tyagi N. Sensitivity analysis of physics and planning complexity in inversely planned volumetric modulated arc therapy.
SmartArc parameters for single and partial arc VMAT planning. J Med Phys. 2012;39:7160–7170.
Appl Clin Med Phys. 2012;13:3760. 17. Sun X, Xia P. A new smoothing procedure to reduce delivery seg-
11. Zhu JH, Chen LX, Jin GH, et al. The study of two‐dimensional dosi- ments for static MLC‐based IMRT planning. Med Phys.
metric verifications of volumetric intensity‐modulated arc therapy 2004;31:1158–1165.