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A dosimetric comparison of coplanar vs. non-coplanar VMAT SBRT techniques for

NSCLC: A Case Study
Authors: Doris Chen, B.S., Wael Makhael, B.S., R.T.(T), Nishele Lenards, M.S., CMD, R.T.(R)
(T), FAAMD, Ashley Hunzeker M.S., CMD
Abstract:
Introduction: The purpose of the study was to dosimetrically compare coplanar and noncoplanar volumetric modulated arc therapy (VMAT) techniques for early stage non-small cell
lung cancer (NSCLC) to determine whether non-coplanar plans could improve the quality of
VMAT stereotactic body radiation therapy (SBRT) lung treatments.
Case Description: Eight patients with left lung tumors of diameters 5cm were randomly
selected. Each coplanar arc plan had 1 full arc and 1 or 2 partial arcs with rotations of 100
-140 with the intention of sparing the contralateral lung without jeopardizing planning target
volume (PTV) coverage. The non-coplanar arc plans were derived from corresponding reference
coplanar plans with the exception of 15couch rotations. The non-coplanar arcs were rotated 15
in the opposite direction to reduce area overlaps. Each patient had a coplanar and a non-coplanar
plan that shared the same optimization objectives. Each individual plan was scored based on ease
of treatment delivery, dose volume histogram (DVH), conformity index (CI), homogeneity index
(HI), and total monitor units (MU). The DVH was used to evaluate the delineated organs at risk
(OR), which included sum lungs, spinal cord, esophagus, heart, chest wall, and skin.
Conclusion: In all plans, the entire PTV was covered by the 95% isodose line and had
comparable CI values. At the 95% confidence level, no statistical differences were found
between the two planning techniques due to small sample size.
Keywords: SBRT, VMAT, NSCLC
Introduction
Lung cancer is the leading cause of cancer mortality due to difficulty in early detection.
Lung cancer has an average five-year survival rate of 54% for localized tumors and an overall
average five-year survival rate of 17.8%.1 Patients with Stage I (T1 or T2, N0, M0) lung cancer
have the options of surgery, radiation, chemotherapy or a combination of treatment modalities.
However, one may refuse surgery or may not be a suitable candidate for surgical intervention.

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When a lesion is inoperable, radiation therapy is the one of the non-surgical modalities to
provide curative care or palliative relief.
If lesions are less than 5 cm in diameter, SBRT is a hypofractionated treatment that
delivers a high dose radiation of 10-30 Gy per fraction.1-2 This procedure incorporates fourdimensional computed tomography (4DCT) and image guidance which both account for patient
respiratory motion. Traditionally, SBRT lung plans were created with three-dimensional
conformal radiation therapy (3DCRT), which uses 10-15 static fields to achieve a distribution
similar to an arc field. However, disadvantages of 3DCRT plans include long treatment times and
high toxicity to OR since lung lesions are often located proximally to radiosensitive structures
(esophagus, heart, lungs, spinal cords, and chest wall) susceptible to acute complications and late
effects such as esophagitis, cardiomyopathy, pneumonitis, myelopathy, and fractures.3 In the
3DCRT technique, preservation of OR without compromising dose distribution to the PTV is
difficult to achieve since dose modulation could not be accomplished with static fields.
When SBRT is delivered with VMAT technique, the arcs use gantry rotation and multileaf collimator (MLC) speed to modulate fluence and dose rate. As a result, VMAT plans are able
to localize high dose to a specific region and at the meantime, reduce high dose spillage to
uninvolved neighboring tissues or organs, shorten treatment times, and decrease MU. Coplanar
VMAT plans yield adequate PTV coverage but the high dose region is generally higher than
desired. Non-coplanar VMAT plans are able to better decrease the global maximum dose and
improve conformity since the planes of non-coplanar plans only intersect at isocenter. However,
since non-coplanar plans have different planar entrances and are spatially spread apart, integral
dose and low dose spillage might be negatively impacted. This can lead to higher integral dose
and an increased risk of secondary malignancies.
On the other hand, a major disadvantage of non-coplanar plans is couch rotation, which
requires the radiation therapists to enter the room and briefly interrupts the treatment. This could
delay the treatment time and impact delivery accuracy as a result of patient movement. The
radiation therapists would have to realign the patient to rectify potential set up errors that
stemmed from couch rotations. The potential for table collisions is a technical drawback of noncoplanar plans, especially when clearing full arcs.
The aim of this research was to evaluate the potential advantages of using non-coplanar
arcs in VMAT SBRT and the contribution of non-coplanar arcs in critical structure preservations

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and hot spot reduction.
Case Description
Patient Selection & Setup
Seven stage I (1A and 1B) NSCLC patients were chosen for this study. The lesions were
located centrally on the left lobe with diameters less than 5 cm and mean PTV volume of 58 cm.3
The mean patient age was 76 years old with a range of 62-89. Among the 8 patients, 5 were
females and 3 were male.
Prior to treatment, each patient underwent CT simulation of 2 mm slice thickness for the
purpose of localizing the tumor and neighboring organs. The placement of positional tattoos was
performed under meticulous attention and extreme precision since SBRT involves treating a
small volume to with high doses. Patients were positioned supine on a wingboard with a headrest
to support the patients head. The arms were extended above the head holding an indexed handle
bar to allow for multiple gantry angles without treating through the arms. For added comfort and
reproducibility, the arms were relaxed against the Wingboard. A Vac-Lok immobilization bag
was placed underneath the patient, which conformed to the patients natural curvature.
Respiratory gating or 4DCT was used to account for target motion in which gating recorded the
spectrum of the breathing cycle to determine the range of tumor movement. The addition of PET
scans helped to further identify the target volume based on the function of biological processes.
Target Delineation
The radiation oncologist defined the clinical target volumes (CTV) that included the
primary disease, nodal involvement, and microscopic findings with abnormal attributes. The
CTVs were expanded 2.5 mm panoramically to create the PTVs. Figure 1 illustrates CTV and
PTV delineations. The contoured OR included the left and right lungs, total lungs (excluding the
CTV), esophagus, spinal cord, chest wall, heart, and skin. The superior limit of the heart began at
the bifurcation of the pulmonary trunk and was contoured until the last visible inferior slice. The
upper limit of the spinal cord represented where the brain stem ended to the level of lumbar
vertebrae 3. The chest wall was a 20 mm expansion laterally, anteriorly, and posteriorly from the
left lung. The most superior aspect of the esophagus started from the cricoid cartilage and
extended down to the gastro-esophageal junction (GEJ), passing the cardiac orifice. The skin, the
most superficial structure, had a uniform 5 mm depth from the body contour. A structure in
which the total lungs excluded the PTV was created to account for the optimization contradiction

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in region of overlap shared by PTV and the left lung. Tissue density corrections were used to
override artifacts in CT scans.
Treatment Planning
The total prescribed dose was 50 Gy over 5 fractions at 10 Gy/fraction. Plans were
created using 6 MV beams for Varian iX linear accelerator commissioned with 5 mm MLC
thickness. The field sizes had a 1 cm margin around the PTV in all directions to account for
penumbra and low secondary electron scattering in lung tissue. The coplanar VMAT plans had
either 2 or 3 arcs with one of the arcs being a full arc and the remaining being partial arcs, which
varied between 100-140. Non-coplanar plans were generated based on the reference coplanar
plan but with 15 couch kicks in the opposite directions to minimize plane overlapping. For
example, if the couch of the full arc was rotated 15, then the couch of the partial arc would be
rotated 345. Figures 2 -3 show the orientations of coplanar and non-coplanar arcs respectively.
The plans were optimized to meet OR constraints and to provide adequate coverage to
PTVs. Depending on the location of each lesion, a set of optimization structures that subtracted
any overlapping region with the PTV were created. The optimization structures helped eliminate
objective conflicts. A planning PTV (pPTV) structure was created to round out the jagged edges
of the original PTV defined by the radiation oncologist. All plans were normalized to 100% of
the prescribed dose covering 95% of the target volume.
Plan Analysis and Evaluation
Coplanar and non-coplanar plans were scored based on total MU, CI, gradient, HI, and
radiation toxicities to critical structures such as lungs, heart, esophagus, spinal cord, and chest
wall. The CI was computed using a Paddicks formula that was modified by Nakamura in Figure
4. Nakamuras new conformity index (NCI) is the reciprocal of Paddicks CI which took into
consideration neighboring normal tissue avoidance.4 The dose gradient of each individual plan
was computed using Paddicks formula which was a ratio of the 50% isodose volume to the
100% isodose volume. Homogeneity indices were calculated based on the difference between the
minimum dose delivered to 95% of the PTV (D5%), and the minimum dose delivered to 95% of
the PTV (D95% ) divided by prescribed dose (DP) then multiplied by 100 to obtain the percentage.5
All of the plans shared the same DP and D95% since the plans had the same prescription dose of
5000 cGy and the same normalization characteristic. A small HI value reflects sharp dose falloff
profile; therefore lower maximum dose and superior homogeneity. Maximum doses were noted

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from the heart, esophagus, skin, and spinal cord to evaluate toxicities. The total lungs were
assessed based on volume receiving 5 Gy (V5Gy), 10 Gy (V10Gy), 12 Gy (V12Gy), and 20 Gy (V20Gy),
and the mean volume (Vmean). The chest wall was evaluated based on dose received by 30 cc
(D30cc) and 60 cc (D60cc) of the chest wall.
The mean and range for CI, HI, gradient, and maximum dose received by the PTV
(PTVmax) for the two planning techniques are demonstrated in Table 1. Non-coplanar plans had
slightly lower mean values for CI, HI, gradient and PTVmax. The amount of normal tissue
receiving 105% of the prescription dose decreased when using non-coplanar. The mean lung
dose comparison between coplanar arcs and non-coplanar arcs is represented in Figure 5. In 5 of
the 7 patients, coplanar plans had significantly lower mean lung dose whereas in Patient 3 and
Patient 5, coplanar and non-coplanar plans yielded similar mean lung doses. The data reflected
non-coplanar plans were better able to reduce the dose to the contralateral lung, specifically, V5Gy
and V12Gy were decreased by 6% and 8% respectively.6-7 However, non-coplanar arcs did not
affect V20Gy, which is the volume used to predict radiation induced pneumonitis. Comparing the
average number of MU per fraction, the MU of the coplanar plan were marginally higher than
the non-coplanar, 2149 MU in coplanar versus 2136 MU in non-coplanar. In addition, the beam
on time of coplanar plan was significantly higher than that of the non-coplanar plan.
Dosimetrically, the most significant finding was the reduction of dose to the heart. The
non-coplanar treatment plans yielded an average of 8% dose reduction in the heart. Figure 6
illustrates that in 5 of the 7 patients, non-coplanar plans were able to improve heart preservation.
Comparing the average dose to spinal cord, the coplanar plan was higher than the non-coplanar
plan. The spinal cord Dmax decreased from 1161 cGy in the coplanar plan to 1126 cGy in the noncoplanar plan, a 2.7% improvement. Improved chest wall toxicities, and esophagus were
observed in the non-coplanar plans for 6 of 7 patients.
Statistical Analysis
Each set of data was tested to determine if its behavior follow a normal distribution. In
order to be considered normally distributed, the Shapiro-Wilk value should be greater than 0.05.
Following the normal distribution test, a Kruskal-Wallis H Test or Anova procedure was applied
to test for significance between coplanar plans and non-coplanar plans. At the 95% confidence
level, when the p-value is less than 0.05, it would be indicative that there is a statistical

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difference between coplanar plans and non-coplanar plans. However, if the p-value is greater
than 0.05, it would reflect no difference between the two techniques.
Conclusion
Although non-coplanar plans may be able to reduce unnecessary radiation toxicities to
critical OR structures, the increase in treatment time may not be optimal for a physically weak
patient who cannot tolerate a slightly extended treatment. If meticulous attention is not paid to
couch rotations, a marginal blunder could miss a significant fraction of the tumor due to its small
size. Zheng et al9 found that the mean survival rates at 1, 3, and 5 years of patients treated with
SBRT were 83.4%, 56.6%, and 41.2%, respectively in comparison to 92.5%, 77.9% and 66.1%
with lobectomy. This suggests currently surgery is the more superior modality, however, if more
research is done on improving SBRT techniques the mode of delivery, SBRT has the potential to
be equally as effective as lobectomy. This study included 8 patients where no statistical
differences were found between coplanar and non-coplanar technique as a consequence of small
sample size. As the patient size increases, the data would be more significant and could
potentially modify the standard of care for stage I, inoperable NSCLC.

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Biol Phy. 2011;81(5):1352-1358. http://dx.doi.org/10.1016/j.ijrobp.2009.07.1751
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. 2013;14(1):228-238.
http://dx.doi.org/10.1016/j.prro.2014.08.009
3. Oliver CT, Mustapha K, Patrice J, et al. Potential benefits of using non-coplanar field and
intensity modulated radiation therapy to preserve the heart in irradiation of lung tumors in the
middle and lower lobes. Radiother Oncol. 2006;80(3):333-340.
http://dx.doi.org/10.1016/j.radonc.2006.07.009
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skull base tumors: analysis of treatment planning parameters. Radiat Oncol. 2006;46(1):1-10.
http://dx.doi.org/10.1186/1748-717X-1-46
5. Tejinder K, Kuldeep S, Vikraman S, et al. Homogeneity index: an objective tool for
assessment of conformal radiation treatments. J Med Phys. 2012;37(4):207213.
http://dx.doi.org/10.4103/0971-6203.103606
6. 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. http://dx.doi.org/10.1016/S0360-3016(99)00183-2
7. Barriger RB, Forquer JA, Brabham JG, et al. A dose-volume analysis of radiation
pneumonitis in non-small cell lung cancer patients treated with stereotactic body radiation
therapy. Int J Radiat Oncol Biol Phys. 2012;82(1):457-462.
http://dx.doi.org/10.1016/j.ijrobp.2010.08.056
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Bio Phy. 2014;90(3):603-611. http://dx.doi.org/10.1016/j.ijrobp.2014.05.055

Figures

Figure 1. A transversal slice taken from the isocenter cut. The orange structure denotes the CTV,
and the PTV, represented in blue, is a 2.5 mm expansion of the CTV.

Figure 2. Coplanar arcs show that the beams rotate about the same axial plane.

Figure 3. Non-coplanar arcs with 15 and 345 couch rotations in the opposition direction show
two separate planes intersecting at the isocenter.

PTV ( volume ) x Prescription Isodose volume

NCI =
2
( volume of PTV covered by prescption Isodose volume )

Figure 4. Nakamuras revised CI formula based on Paddicks original formula.

Mean Lung Dose

700
600
500
Coplanar

400

Dose (cGy)

Non-coplanar

300
200
100
0

Figure 5. Mean lung dose comparison between coplanar and non-coplanar plans.

Heart Dose (Dmax)

CGy

1000
900
800
700
600
500
400
300
200
100
0

Patient 1

Patient 2

Patient 3

Patient 4

Patient 5

Patient 6

Figure 6. Maximum heart dose comparison between coplanar and non-coplanar plans.

Patient 7

Tables
Table 1. Conformity index, homogeneity index, gradient, and PTVmax comparison of the two
VMAT techniques.
Parameter

Coplanar

Non-Coplanar

Conformity Index
Mean
Range

1.30
1.13 to 1.5

1.22
1.14-1.30

14.5
9.4-19

14
8.9-17.9

4.6
3.4 to 5.8

4.4
3.4-6.1

117.2%
112.2-123

117.1%
109.4-122.6

Homogeneity Index
Mean
Range
Gradient
Mean
Range
PTV max
Mean
Range