Medical Dosimetry

Continuation of: Exploiting Tumor Position Differences between Deep Inspiration and
Expiration in Lung Stereotactic Body Radiation Therapy Planning

Jarrett Bielata, BSRT (T)

Eric Rauchenstein, BSRT (T)
Carmine Verna, BSRT (T)
Christina Clare Huang, BS
Kevin Shiue, MD
Greg Bartlett, CMD
Namita Agrawal, MD
Mona Arbab, MD
Peter Maxim, PhD
Colleen DesRosiers, PhD
Todd Mereniuk, MD, PhD
Susannah Ellsworth, MD
Ryan Rhome, MD, PhD
Jordan Holmes, MD
Mark Langer, MD
Richard Zellars, MD
Tim Lautenschlaeger, MD, PhD
Abstract

Purpose:
It has been shown that it is possible to reduce normal tissue doses to the chest wall in lung stereotactic body
radiation therapy (SBRT) for mobile tumors, if the treatment dose is planned to be split between opposite respiratory
states. This particular study will be an additional contribution of n = 10 to the aforementioned study listed above (n
= 4) and will compare chest wall dose from the composite plan versus the previously treated plan.
Methods:
Patients were deemed eligible if they were treated with either three or five fraction lung SBRT at Indiana University
Health and received deep inspiration breath hold (DIBH) and free breathing 4D computed tomography (CT) scans at
simulation. These scans were performed as part of routine simulation procedures for treating the cancer at hand.
Volumetric modulated arc therapy plans were created on both scans with each plan delivering half of the prescribed
dose. Two registrations of the CT scans were then completed to evaluate the composite plan. The chest wall and
ribs near the tumor were registered on both CT scans to evaluate chest wall doses, and a second registration of the
Gross Tumor Volume (GTV) was also done for evaluation of target coverage. This is a retrospective study of lung
SBRT treatments, evaluating the potential dosimetric benefit of composite DIBH-expiration treatment.
Results:
Ten patients with ten total tumors had requisite planning scans available. Tumor size was between 0.86-4.2 cm and
tumor movement 0.9-4.3cm The mean amount of cc’s of V30 Gy in the chest wall (CW) for the ten composite plans
compared to the ten treated plans was 4.1cc [range 0 to 21.24cc]. The treated plan had a mean of 16.5cc [range 0.01
to 53.96cc] treated for a mean reduction of 67.3%. The mean reduction of the CW max dose was reduced by 28.7%
(from 4653 cGy to 3753 cGy) [total range 1194cGy increase to 2650cGy decrease] compared to the treated plan.
Greater reduction in CW maximum dose was observed when a patient had no overlap in planning target volumes
between DIBH and expiration phases (reduction of 49.5% for no overlap vs mean reduction of 13.8% with overlap).
For nine of the ten patients, the composite plan met constraints in terms of PTV coverage & CW constraint doses.
For the TG101 & UK guidelines only two of the four eligible patients met all constraints.
Conclusions:
We conclude that composite DIBH-expiration SBRT planning has continued to show much promise in improving
organ at risk sparing. However, many variables need to be considered while planning and treating these patients
such as the cost-time function, reproducibility of the treatment plan, and patient compliance in accordance to breath
holding & overall treatment time which should be evaluated in future studies.
Introduction
Lung cancer accounts for 25% of all cancer related deaths in the United States (1). Approximately 230,000 new lung
cancer cases will be found in 2020 (1). The standard of care for NSCLC has historically been surgical resection
until recently where external beam radiation therapy has found to be beneficial. Like many other cancers, treatment
regimens are dependent on the extent of the disease. Early stage lung carcinomas where patients experience other
comorbidities are typically poor candidates for surgical intervention. Recently, stereotactic body radiotherapy
(SBRT) has emerged as a highly promising therapeutic option for these patients. A recent phase 2 study for
medically unresectable patients demonstrated a 3-year primary tumor control rate of 97% with SBRT (2). SBRT has
also been used as a safe and effective method to treat most previously treated areas. To this day, many radiation
oncology departments around the world have developed protocols using SBRT as commonplace to treat these types
of patients.

One of the primary complications of delivering lung SBRT treatments is the tumor motion which may potentially
cause a miss of the target volume. Tumors closer to the diaphragm generally move the most, while tumors towards
the apices of the lung will typically move less. Nevertheless, it has been shown that it is always vital to monitor
tumor motion according to Stevens (3). Tumor motion is not predictable by tumor size or location, or pulmonary
function test results (3). Therefore, tumor motion must be measured in all patients. Measurements in all three
dimensions will likely be necessary to maximize the irradiated lung volumes or choose beam arrangements parallel
to the major axis of motion (3). Set-ups for patients need to be reproducible and require strict imaging protocols to
maximize the accuracy of treatment.

Techniques used to control tumor motion include transition to prominently chest wall breathing through abdominal
compression, tumor tracking, and taking advantage of respiratory cycle reproducibility through gating and deep
inspiration breath hold (DIBH) (4)(7). DIBH reduces variability in tumor location by reproducing the same point in
the breathing cycle during treatment delivery. In gated treatments, the respiratory cycle is monitored, and radiation is
only delivered during a specified phase of the respiratory cycle (4)(7).

Chest wall pain and radio-pathologic fracture are known adverse effects of SBRT when treating peripheral lung
tumors that are proximal to the chest wall. Some doses and volumes have been cited to give an accurate
representation of chest wall toxicity. V30Gy should be limited to a threshold of less than 30cc of volume to prevent
pain or fracture (5). There have been studies that have shown that if the V30 Gy were to exceed 30cc for a three
fraction regimen, then it was recommended to increase the fraction size to 5 fractions (6). This would allow planning
staff to optimize the chest-wall based on a V37 Gy which is biologically equivalent to a V30 Gy in a three fraction
setting (6).

This study will continue to utilize the same techniques used in the previous study as this planning technique and
delivery method will potentially allow the sparing of normal tissues by exploiting tumor motion secondary to
respiration (7). Many lung tumors, especially the ones located inferiorly, can be significantly displaced with DIBH.
It was hypothesized that the difference in tumor position between two respiratory states relative to normal structures
could be exploited in radiation planning (7).

Materials & Methods

This is a retrospective study of lung SBRT treatments, evaluating the potential dosimetric benefit of composite
DIBH-expiration treatment. Patients were deemed eligible if they were treated with either three or five fraction lung
SBRT at Indiana University Health and received deep inspiration breath hold (DIBH) and free breathing 4D
computed tomography (CT) scans at simulation. These scans were performed as part of routine simulation
procedures for treating the cancer at hand.

Simulation: Patients were simulated in a supine position with immobilization via an SBRT positioning system, and
respiratory management with the Real-time Position Management Respiratory Gating system. At simulation, a
4DCT was obtained recording 10 respiratory phases (0% to 90%) while free breathing. A separate DIBH scan was
obtained subsequently. The radiation oncologist and physicist verified the suitability of respiratory management
options for each patient, and reviewed image data sets to ensure adequacy for planning.

Treatment Planning: It was first determined that the 50% respiratory phase of the 4DCT was the expiration phase.
The chest wall was then aligned by fusing the 50% scan from the 4DCT with the patient’s DIBH scan in order to
accurately measure chest wall doses when treating at DIBH and expiration. The target volumes and chest wall
structures were transferred from the DIBH scan to the 4DCT in order to accurately determine PTV overlap.
Depending on the amount of overlap, the PTV was divided into sections as differing dose levels. PTVs were divided
into a high and low section if there was approximately 50% overlap. A high, mid, and low section was created
(Figure 4) when there was between 1% and 50% overlap. Once contouring was completed, identical treatment plans
were created on both the 50% phase and the DIBH. All plans were created on Varian Eclipse version 15 with
volumetric modulated arc therapy (VMAT) and 6x flattening filter free (FFF) beams. Each plan was prescribed half
of the original Rx when optimizing for ease of evaluation in future plan sums. If the PTVs had approximately 50%
overlap, the PTV high was treated to 132% the prescription dose (Rx), and the PTV low was treated to 66%. If the
PTVs had 1% to 50% overlap, the PTV high was treated to 132% the Rx, PTV mid was treated to the Rx, and PTV
low was treated to 66% of the Rx. The plans were then summed in order to evaluate chest wall constraints. The
DIBH scan was then broken from its reference frame and fused with the original DIBH scan. Finally, the contours
were copied over to the broken scan. The plan created on the original DIBH scan was then copied and pasted to the
broken DIBH and calculated. Once the plan was calculated, the broken DIBH scan was fused to the 50% phase
according to the GTV (Figure 3). The 50% phase plan and the broken DIBH plan were then summed for target
coverage evaluation (Figure 2).
DVH Analysis: The chest wall contour was generated as a 2cm expansion from the lung and included ribs, which
were not separately analyzed. Coverage goals were set for the PTV (95% of PTV to be covered by 100% of
prescription dose). ITV and GTV volumes were not boosted to ~120% of the Rx as is typical in lung SBRT cases to
mitigate high dose region discrepancies between plans. To compare radiation dose to the chest wall, the following
parameters were extracted: Dmax, D0.03cc, D0.5cc, D1cc, D5cc, D10cc, D20cc, D30cc, V3Gy, V5Gy, V30Gy, and
V45Gy. The dose to each parameter was extracted from the DVH, and then numerical and percentage differences
were calculated to determine the effectiveness of the treatment

Results
Ten lung SBRT patients had both DIBH and 4D scans available to plan from. All lesions were located within 1 cm
of the chest wall. The mean longest tumor diameter was 2.2cm [range: 0.86-4.2cm]. The mean overall tumor
movement was 2.27cm [range: 0.9-4.3cm]. Four of the ten patients had GTV overlap whereas nine of the ten
patients contained some form of PTV overlap. On the composite plan, all patients had excellent coverage of the PTV
V100% which had a mean increase of 5.6% [range of 90.7% to 99.3%] when compared to the previously treated
plan [mean of 90.7%, range 69.8% to 99.1%]. For 54 Gy in 3 Fx & 50 Gy in 5 Fx cases, the mean V100% was
95.8% and 96.7% respectively. The previously treated patient data cited means of 96.2% & 87% for 54 Gy/3 Fx and
50 Gy/5 Fx respectively (Table 1).

The mean amount of cc’s of V30 Gy in the chest wall (CW) for the n=10 composite plans compared to the n=10
treated plans was 4.1cc [range 0 to 21.24cc]. The treated plan had a mean of 16.5cc [range 0.01 to 53.96cc] treated
for a mean reduction of 67.3%. The 54 Gy/3 Fx & 50 Gy/5 Fx regimens for the composite recorded 1cc & 6.3cc
mean values respectively. The previously treated plan recorded 7.6cc & 22.5cc receiving V30 Gy for 54 Gy/3 Fx
and 50 Gy/5 Fx respectively (Tables 3-5).

The mean reduction of the CW max dose has been reduced by 28.7% (from 4653 cGy to 3753 cGy) [total range
1194cGy increase to 2650cGy decrease] compared to the treated plan. For 54 Gy/3 Fx and 50 Gy/5 Fx cases the
average max doses were 3750 cGy & 3755 cGy respectively; the previously treated plan cited 3839 cGy & 5196
cGy for the same dose schemes (Tables 3-5).

Furthermore, mean reductions in chest wall doses for D5cc (average 1217 cGy), D10cc (1077 cGy), D20cc (844
cGy), & D30cc (701 cGy) had been reduced for all of the composite plans vs. the previously treated plans. This is
also inclusive for the 54 Gy/3 Fx and 50 Gy/5 Fx regimens (Tables 3-5).

The following parameters cited the following reductions: Mean chest wall doses for D0.3cc (average 1047 cGy),
D0.5cc (1084 cGy), D1cc (1144 cGy), & CW V30 (average 67.3%) were substantially reduced for all patients
except patient 001 (50% overlap of the PTV’s). Reductions were also visualized with all 54 Gy/3 Fx and 50 Gy/5 Fx
regimens (Tables 3-5).
Evaluation of low doses to the chest walls is displayed by the V5 Gy and the V3 Gy. V5 Gy reported a mean
decrease of 3.5% [range of 33% increase & 78% decrease] and a mean absolute decrease of 5.1cc [range of 82cc
increase & 203cc decrease]. The V3 Gy reported a mean decrease of 12.8% [range of 30% increase & 81%
decrease] and a mean absolute decrease of 12.4cc [range of 39cc increase & 194cc decrease]. For 54 Gy/3 Fx there
was a decrease of 38% & 42% compared to the treated plan for V3 Gy & V5 Gy respectively. However, the same
was not displayed for the 50 Gy/5 Fx. There was a noticeable increase of low dose to the chest wall compared to the
treated plan for V3 Gy (19.5% increase) & V5 Gy (6.5% increase) (Tables 3-5).

High doses were also compared in this study by the V45 Gy metric. Virtually zero [range .01-0.03cc] volume
received 45 Gy to the chest wall in all composite plans compared to the treated plans which recorded averages of
1.7cc, 5.5cc and 3.9cc for 54 Gy/3 Fx, 50 Gy/5 Fx, and sums of both regimens respectively (Tables 3-5).

To assess if the composite DIBH-expiration planning improves DVH parameters for the chest wall
enough to consider delivering SBRT in three fractions instead of five fractions, radiation plans delivering
54Gy in 3 fractions were generated (Table 2) (7). TG101 and UK lung SBRT guidelines include chest wall
constraints D0.03cc (max dose), D0.5cc, D1cc, and D30cc (Table 2) (7).

Of the four eligible patients in this study, only the composite plans of patients #02 and #09 would meet the
constraints for both TG101 & the UK lung SBRT guidelines. UK guidelines would also accept the constraints of
patient #01 under their guidelines. The max dose, D0.5cc, and D1cc parameters had all decreased for three out of the
four patients compared to the treated plan (patient #01 it had increased). The D30cc had improved in all four
patients when compared to the treated plan (Table 2).

Discussion
As a continuation of the previous study on using DIBH-expiration SBRT planning methods, this study sought to
further assess the validity of these planning methods in order to significantly reduce doses to OARs adjacent to the
tumor. While the previous study also focused on reducing heart and low dose to lung, the current study specifically
focused on ten patients with tumors in close proximity to the chest wall. The objective was to reduce chest wall
dose as much as possible while still delivering prescription dose to the PTV volume. The results of the study were
able to consistently show a decrease in chest wall dose while in many cases increasing the PTV V100%, with a
recorded mean increase of 5.6% when comparing the treated plan and the composite plan. Notable decrease in the
volume (cc) receiving 30 Gy was also found with the composite plan with a V30 Gy mean of 4.1 cc and the treated
plan mean of 16.5 cc. In all but one case, chest wall maximum dose was also decreased with a mean decrease of
28.7% for the ten patients studied. The increase of maximum dose to this particular patient in the study is likely due
to the small tumor volume size (<1cm diameter) and relatively small tumor displacement (0.9cm) between the DIBH
and expiration plans. Additionally, D5cc, D10cc, D20cc and D30cc all displayed mean reductions of dose when
comparing the composite plan against the original treated plan. When comparing low dose levels between the plans,
V3 Gy and V5 Gy were utilized. While the 54Gy/3 fx plans did show a decrease in V3 Gy (decreased 38%) and V5
Gy (decreased 42%), patients that were treated with a 50 Gy/5 fx plan had an increase in low dose with V3 Gy
increasing 19.5% and V5 increasing 6.5% in the composite plans. However, high dose levels of the composite plans
did show improved reduction with a V45 Gy ranging from 0.01-0.03cc.

While the collected data from this study does offer promising results, further research and study must be done to
alleviate the limitations of using these planning methods. The time required for dosimetric planning of the DIBH-
expiration method used in this study is significantly longer than creating a traditional lung SBRT plan. This
additional time is accounted for in the need to contour on two image sets instead of one, creation of dose
optimization structures, creation of two plans each with a separate isocenter, breaking of image registrations,
completing new registrations to evaluate chest wall dose, the dose distribution, and in creating plan sums. The
benefit in boosting the dose inside the GTV volume along with a rapid dose fall-off for traditional SBRT planning is
also largely lost with the need to deliver 2 or 3 dose levels to the PTV volume.

Additional studies must be focused on the ability of the two composite treatment plans to be delivered accurately to
the patient. Regardless of the data that can be collected from the treatment planning system, if the planned dose
distribution does not match the prescribed dose, it cannot be considered a viable or safe treatment technique for
patient use. With this planning technique utilizing two plans to deliver the prescribed dose, the time required for
treatment delivery will also likely be increased. Each plan will require localization to a different isocenter requiring
multiple CBCTs to verify tumor alignment at each isocenter. This additional time to deliver treatment also increases
the potential for intrafraction movement.

Regardless of the limitations of this study, the significant decrease in chest wall doses deserves further study on the
topic. The DIBH-expiration planning method consistently demonstrated a drastic reduction in OAR doses, while in
many cases increased the PTV target volume coverage.

Conclusion
While the delivery of hypofractionated SBRT treatments to lung tumors have shown positive tumoricidal effects, the
delivery of these high doses in short fraction schemes can have an equally negative impact on adjacent OARs, such
as the chest wall. This study, in combination with the previous study, both demonstrate a treatment planning method
by which chest wall doses could be significantly reduced while in many cases offering improved prescription dose
coverage to the PTV volume. We do conclude that there are limitations of this planning method as it currently exists
that need to be resolved and studied further to test the validity and reliability of this planning technique. However, it
cannot be denied that the DIBH-expiration planning method for SBRT offers further evidence that it is possible to
reduce OAR doses by exploiting tumor motion through phases of breathing. This study offers a promising
foundation from which further OAR sparing for lung SBRT treatments can be studied and built upon.
Figure Captions

Figure 1:

Blended image portraying overlap between the PTV+GTV 50% (Orange + Red) & the PTV DIBH (Blue+Purple) [PT004]

Figure 2:

95% (4750 cGy) color wash on the PTV/GTV DIBH fusion + DVH of PTV (blue) & GTV (Pink) [PT004]
Figure 3:

25 Gy color wash on the chest wall evaluation plan sum. DVH at 30Gy with 3.3cc volume irradiated [PT004]
Figure 4:
Tri-level structures contoured. Top orange PTV is divided into parts: PTV Low (yellow), PTV Mid (red), and PTV High
(orange) [PT004]

References:

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Exploiting tumor position differences between deep inspiration and expiration in lung stereotactic body
radiation therapy planning. Medical Dosimetry. doi: 10.1016/j.meddos.2020.02.002

Patient Tumor Max GTV PTV PTV Rx PTV V100% PTV

# Diameter Tumor Overlap Overlap Distance (Composite) V100%
(cm) Moveme to Chestwall (Treated
nt (cm) Plan)

#01 0.86 cm 0.9 No Yes 0.8 cm 3fx to 54Gy 99.20% 95.50%

#02 1.7 cm 2.4 No Yes 0.5 cm 3fx to 54Gy 96.71% 99.11%

#03 1.2 cm 4.3 No No 0 cm 5fx to 50Gy 98.66% 69.80%

#04 2.3 cm 2.8 No Yes 0 cm 5fx to 50Gy 96.19% 98.40%

#05 2.5 cm 2.5 Yes Yes 0 cm 5fx to 50Gy 93.50% 94.01%

 #06 4.2 cm 3.3 No Yes 0 cm 5fx to 55Gy 95.49% 68.51%

#07 2.4 cm 1.8 Yes Yes 0 cm 5fx to 50Gy 96.97% 96.80%

#08 2.5 cm 2.3 No Yes 0.6 cm 3fx to 54Gy 99.25% 95.04%

#09 1.4 cm 1 Yes Yes 0.8 cm 3fx to 54Gy 96.43% 95%

#10 3.1 cm 1.4 Yes Yes 0 cm 5fx to 50Gy 90.70% 95.25%

Table 1: Overview of patient data

TG101 UK Cut-off
Cut-off Max Dose: D1cc: D30cc: D0.5cc: D30cc:
Dose 3690 cGy 2880 cGy 3000 cGy 3700cGy 3000cGy

Patient# 01 Original Treatment 3276 2568 907 2744 907

Composite 4470 2898 514 3329 514

Patient #02 Original Treatment 3204 2551 1924 2650 1924

Composite 2097 1784 1308 1844 1308

Patient #08 Original Treatment 3564 3055 1706 3207 1706

Composite 3384 2512 1366 2672 1366

Patient #09 Original Treatment 5310 5050 2972 5114 2972

Composite 5050 3646 864 4031 864

Table 2: Overview of 54Gy/3Fx SBRT Chest Wall Dose Volume Histogram (DVH) Parameters According to TG101 and UK
Guidelines: green: constraint met; red: constraint not met.
 5 Fraction Composite Plan vs Composite Plan vs
Plans Originally Treated Plan Original Treatment Plan
% Reduced from Value Reduced from
Originally Treated Plan Original Treatment Plan
(Original-Composite), (Original-Composite),
Mean (Range) Mean (Range)

CW Max (cGy) 27.56% (18.2% to 49.5%) 1440.67 (964 to 2650)

CW D0.3cc 29.58% (20.2% to 48.3%) 1485.5 (801 to 2482)

(cGy)

CW D0.5cc 30.08% (20.5% to 48.2% 1500.67 (792 to 2459)

(cGy)

CW D1cc (cGy) 30.64% (20.2% to 47.7%) 1509.67 (748 to 2394)

CW D5cc (cGy) 31.51% (18.2% to 44.4%) 1371.67 (581 to 1789)

CW D10cc (cGy) 29.80% (16.9% to 44.5%) 1101.5 (493 to 1354)

CW D20cc (cGy) 26.98% (17.1% to 37.7%) 787.67 (450 to 1080)

CW D30cc (cGy) 24.45% (17.6% to 34.2%) 591.5 (434 to 955)

CW V3Gy (cc) -19.48% (-32.9% to 5.7%) -43.9 (-82.1 to 3.4)

CW V5Gy (cc) -6.54% (-30.0% to 12.0%) -14.75 (-39.4 to 23.2)

CW V30Gy (cc) 79.31% (60.6% to 100%) 16.19 (7.4 to 32.7)

CW V45Gy (cc) 100% 5.45 (0.01 to 13.7)

Table 3: Summary of 5 Fraction Chest Wall (CW) Histogram (DVH) Relative Changes: CW values
between treated plan and composite plan.

3 Fraction Plans Composite Plan vs Composite Plan vs

Original Treatment Plan
% Reduced from
Original Treatment Plan
(Original-Composite),
Mean (Range)
Original Treatment Plan
Value Reduced from
Original Treatment Plan
(Original-Composite),
Mean (Range)

CW Max (cGy) 2.01% (-36.5% to 34.6%) 88.25 (-1194 to 1107)

CW D0.3cc (cGy) 9.82% (-24.8% to 30.6%) 388.0 (-706 to 909)

 CW D0.5cc (cGy) 11.74% (-21.3% to 30.4%) 459.75 (-585 to 1083)

CW D1cc (cGy) 15.70% (-12.9% to 30.1%) 596 (-330 to 1404)

CW D5cc (cGy) 31.99% (21.5% to 44.0%) 985.5 (556 to 2051)

CW D10cc (cGy) 38.28% (23.1% to 52.1%) 1039.5 (539 to 2162)

CW D20cc (cGy) 40.11% (21.6% to 63.2%) 928.25 (426 to 2147)

CW D30cc (cGy) 41.55% (19.9% to 70.9%) 864.25 (340 to 2108)

CW V3Gy (cc) 37.9% (-12.3% to 78.2%) 78.6 (-13.1 to 202.8)

CW V5Gy (cc) 41.68% (-7.9% to 81.0% 72.88 (-7.4 to 193.5)

CW V30Gy (cc) -101.6% (-690.9% to 100%) 6.62 (-0.8 to 26.0)

CW V45Gy (cc) 24.58% (0% to 98.3%) 1.62 (0 to 6.47)

Table 4: Summary of 54Gy/3Fx Chest Wall (CW) volume histogram (DVH) differences between treated plan and composite
plan.

Average between Composite Plan vs Composite Plan vs

3 Fx & 5 Fx plans Original Treatment Plan Original Treatment Plan
% Reduced from Value Reduced from
Original Treatment Plan Original Treatment Plan
(Original-Composite), (Original-Composite),
Mean (Range) Mean (Range)

CW Max (cGy) 17.34 % 899.7 cGy

CW D0.3cc (cGy) 21.68 % 1046.5 cGy

CW D0.5cc (cGy) 22.74 % 1084.3 cGy

CW D1cc (cGy) 24.67 % 1144.2 cGy

CW D5cc (cGy) 31.7 % 1217.2 cGy

CW D10cc (cGy) 33.19 % 1076.7 cGy

 CW D20cc (cGy) 32.23 % 843.9 cGy

CW D30cc (cGy) 31.29 % 700.6 cGy

CW V3Gy (cc) 3.48 % 5.1 cc

CW V5Gy (cc) 12.75 % 20.3 cc

CW V30Gy (cc) 6.96 % 12.36 cc

CW V45Gy (cc) 99.76 % 5.6 cc

Table 5: Averaged dose regimens (5 Fx & 3 Fx) Chest Wall (CW) volume histogram (DVH) differences between treated &
composite plan.