Journal Club Research Article-V
Presented By,
Anu Roy
Intern Medical Physicist
SRMS Institute of Medical Sciences
Bareilly, UP
Comparison of three Radiotherapy Techniques Volumetric
Modulated Arc Therapy with Variable and Constant Dose
Rate and Intensity-Modulated Radiotherapy for the
Irradiation of Five Cancer Sites
Authors: Varsha Raghunathji Gedam et al.
Department of Medical Physics,
Delhi State Cancer Institute,
Year of Publication : 2022
Journal : Journal of Biomedical Physics and Engineering
INTRODUCTION
Intensity-modulated radiation therapy (IMRT) is mostly considered a treatment for many
cancer cases due to its advantage in planning target volume (PTV) coverage and organ-
at-risk OAR sparing.
It requires a longer treatment delivery time, leading to intra-fraction positional error.
This could impact under dose PTV and overdose to OAR.
The VMAT with variable dose rate (VDR VMAT) machine is more expensive than Co-
60 or conventional LINACs.
This study aimed to explore the feasibility and potential benefits of the CDR VMAT
technique based on its dosimetric comparison with IMRT and VDR VMAT for 5
complex cancer sites, including, brain, head-neck, lung, esophagus, and prostate.
MATERIALS AND METHODS
In this study, 75 cancer patients participated, who were with the diagnosis of brain,
head-neck, lung, esophagus, and prostate.
A total of 15 patients were randomly selected from each cancer site, and each
patient was immobilized with a thermoplastic cast and simulated on a computed
tomographic (CT) simulator (SOMATOM, SIEMENS, Germany) in a supine
position.
The 3-mm slices were acquired for all cases. The radiation oncologist delineated
the target volumes and OAR structures in the monacosim contouring station
(ELEKTA, Crawley, UK) for each site.
For 75 patients, 225 plans, including 75 VDR VMAT, 75 CDR VMAT, and 75
IMRT were designed using the Monte Carlo algorithm on Monaco (Elekta Medical
Solutions) treatment planning system version 5.11.01.
This planning was used the prescription 54 Gy in 30 fractions for the brain, 60 Gy in
30 fractions for the lung, 78 Gy in 39 fractions for the prostate, 45 Gy in 25 fractions
for esophagus, and 70/63/54 Gy in 35 fractions for head-neck cases.
Step and shoot IMRT (S&S IMRT) plans were created using 5–9 fields for 6 MV
Oncor Expression Linac.
The VDR-VMAT plans for the brain, lung, esophagus, and prostate were designed
using 6 MV photons with one coplanar arc of 360˚, consisting of clockwise and
counter-clockwise rotation.
Head-neck plans were created and computed using dual coplanar arcs of 360˚ rotation
for a maximum dose rate 320 MU/min, collimator angle 5˚, 0.5 cm segment width,
medium fluence smoothening, and 3 mm grid size.
CDR-VMAT plans were generated by a constant dose rate of 320 MU/min.
The IMRT, VDR VMAT, and CDR VMAT plans were optimized to achieve the dose
constraints.
The Monte Carlo algorithm uses XVMC code19 for dose calculation, based on the
virtual energy fluence model.
Three techniques were dosimetrically compared based on the evaluation of dose-
volume- histogram (DVH) parameters, the maximum dose to PTV (D2), the mean dose
to PTV, and PTV coverage.
The plan quality was analyzed by comparing the homogeneity index (HI) and Paddick”s
conformity index (CI) .
CI=TVRI2/(TV x VRI)
where TV is the target volume, TVRI is the target volume encompassed by reference
isodose, and VRI is the volume of the reference isodose.
HI= (D2-D98)/ D50
where D50 is the dose covering 50% of PTV, D2 is the dose covering 2% of PTV, and
D98 is the dose covering 98% of PTV .
Treatment delivery parameters, including monitor units (MU) and treatment
delivery time, were evaluated and compared for CDR, VDR VMAT, and IMRT.
For OAR evaluation, mean doses, maximum doses, and volume doses were
compared for all five tumor sites.
The CDR VMAT, VDR VMAT, and S&S IMRT were statistically compared.
RESULTS
The CI was higher in VDR and CDR VMAT plans than IMRT for all five cancer
sites.
Both VMAT (VDR and CDR) and IMRT plans were homogeneous .
The PTV coverage V95 was more than 95%, and all OAR parameters were
comparable for all five tumor sites in all three techniques.
The OAR doses in the head- neck, such as the brainstem, optic chiasm, and optic
nerve had no significant difference in CDR, VDR, and IMRT.
Treatment delivery time was lower in VDR and CDR VMAT compared to IMRT.
The CDR VMAT reduced the treatment time to 72-80% compared to IMRT.
DISCUSSION
The current study shows that the CDR VMAT technique produces a clinically
acceptable plan as IMRT and VDR VMAT for nearly all tumor sites with optimum
PTV coverage, more conformed dose distribution, and minimal doses to OAR.
The PTV coverage was similar in all the techniques .For all five sites, CDR VMAT
provides clinically acceptable plans with better PTV coverage, more conformed dose
distribution, and OAR sparing with a shorter treatment delivery time.
The total number of MU was higher in CDR VMAT, but treatment delivery time was
significantly shorter compared to IMRT in all five cancer sites, leading to reducing
intra fraction motion errors and improving patient comfort. The obtained results were
consistent with the study of Didona et.al. In which 15 head and neck plans.
This study demonstrated that the CDR VMAT technique produces clinically
acceptable plans, such as VDR VMAT and IMRT for nearly all tumour sites.
Therefore, this cost-effective technique is considered better for the patient and the
institute to improve the patient’s quality of life by better quality treatment for more
patients .
Due to the unavailability of advanced technology this CDR VMAT technique can be
used to increase patient throughput with more conformed dose distribution and
better PTV coverage with safe OAR.
CONCLUSION
Based on comparing CDR, VDR, and IMRT techniques, the CDR VMAT technique
can provide more conformed dose distribution, resulting in quality plans with good
PTV coverage and sparing OAR as VDR VMAT and IMRT in all five tumour sites,
such as brain, head-neck, lung, oesophagus, and prostate.
Furthermore, the CDR VMAT may also reduce intra-fraction motion errors with a
shorter treatment delivery time to improve patient comfort.
Moreover, with these advantages and its cost-effectiveness, the CDR VMAT
technique may be a promising treatment technique in radiotherapy practice.
