Research Proposal (Quantitative)

Title: Simultaneous integrated boost (SIB) volumetric modulated arc therapy (VMAT) planning
of anorectal disease utilizing Eclipse: implications to organs-at-risk (OAR) with jaw tracking
(JT) vs. static jaw (SJ).

Literature Review (Introduction):

Volumetric modulated arc therapy (VMAT) has enabled the utilization of tighter margins
and higher prescription doses for target volumes while improving the ability to spare organs-at-
risk (OAR). However, despite the use of VMAT, patients receiving radiation for anorectal
cancers continue to experience devastating acute and chronic toxicities due to the large amounts
of healthy pelvic tissue being irradiated, and those receiving concurrent chemoradiation are even
more susceptible to developing complications. Common toxicities experienced by patients
receiving pelvic irradiation include GI, GU, hematological toxicities (HT), and sexual
dysfunction.1 Radiation Therapy Oncology Group (RTOG) 0529 was a phase II study of
chemoradiation with intensity modulated radiation therapy (IMRT) for anal cancer patients. In
this study, 73% of patients experienced acute grade 2 or higher GI toxicities and 10% of patients
experienced late grade 2 or higher GI toxicities. Additionally, 15% of patients experienced acute
grade 2 or higher GU toxicities and 4% experienced late grade 2 or higher toxicities.2 Therefore,
in an effort to reduce toxicities, it is essential to avoid unnecessary dose to small and large
bowel, bladder, femoral heads, iliac crests, and external genitalia in anorectal patients.
Volumetric modulated arc therapy is a useful technique for limiting dose to OAR in the pelvis.
However, radiation leakage between the multileaf collimator (MLC) during VMAT delivery
contributes to unwanted dose outside of the targets.

Traditional IMRT planning techniques utilize a static jaw (SJ) in which the jaw remains
locked and open at the greatest MLC field dimension for the entirety of treatment delivery. When
treating with the traditional static jaw technique, unnecessary MLC interleaf transmission occurs
through the open jaws despite the MLCs conforming to the target. According to Mohan et al,3
dose differences between utilizing MLCs only and MLCs and jaw measured from 2%-3% for 6
MV and between 3.5% and 5% for 18 MV photon energies. In an effort to minimize interleaf
transmission and limit excess dose to OAR, advances were made in which the jaws would move
with the MLC modulation: a modern technique called jaw tracking (JT).
 Prior research shows the benefits of JT in both reducing dose to OAR and improving
target coverage and homogeneity. A broad study by Wu et al4 compared 10 head and neck, 10
lung, 10 gastric, and 10 cervical patients planned with both static jaw and dynamic jaw tracking
and found that the additional shielding of JT reduced the maximum and mean doses to OAR and
slightly reduced mean dose to targets. Based on the multiple treatment sites researched, Wu et al4
concluded that there was an increased benefit from jaw tracking for large irregularly shaped
targets because the dynamic jaws have a greater range for adjustments as the gantry rotates
around the patient. Wu et al4 also concluded that OAR receiving lower doses such as the gonads
and red bone marrow in cervical patients benefitted significantly with the use of JT. The findings
in the Wu et al4 research were consistent with Yao et al5 and Feng et al6 also indicating that the
benefits of JT were more significant in treatment plans of large non-spherical target volumes and
for OAR farther from the target. However, there remains a dearth of literature evaluating the
effects of JT on OAR and target coverage for large irregularly shaped anorectal target volumes.
The problem is that interleaf transmission from static jawSJ techniques could be delivering
unnecessary dose to OAR when treating anorectal patients with VMAT. The purpose of this
study is to determine whether the use of JT will improve OAR sparing in large non-spherical
anorectal VMAT plans.

Problem Statement:

Interleaf transmission from static jaw SJ techniques could be delivering unnecessary dose to
OAR when treating anorectal patients with VMAT.

Purpose Statement:

The purpose of this study is to determine whether the use of JT will improve OAR sparing in
large non-spherical anorectal VMAT plans.

Hypotheses:

The first research hypothesis (H1) is that using jaw trackingJT for anorectal VMAT plans will
reduce the mean dose to the bladder. The first null hypothesis (H10) is that using jaw tracking for
anorectal VMAT plans will not reduce the mean dose to the bladder.
The second research hypothesis (H2) is that using JT for anorectal VMAT plans will reduce the
mean dose to the iliac crests. The second null hypothesis (H20) is that using jaw tracking for
anorectal VMAT plans will not reduce the mean dose to the iliac crests.

The third research hypothesis (H3) is that using JT for anorectal VMAT plans will reduce the
mean dose to the bowel. The third null hypothesis (H30) is that using jaw tracking for anorectal
VMAT plans will not reduce the mean dose to the bowel.

The fourth research hypothesis (H4) is that using JT for anorectal VMAT plans will reduce the
maximum dose to the bowel. The fourth null hypothesis (H40) is that using jaw tracking for
anorectal VMAT plans will not reduce the maximum dose to the bowel.

Materials and Methods:

Ten anorectal patients with nodal involvement will be planned utilizing VMAT SIB
technique (54 Gy, 45 Gy in 30 fractions). This is a retrospective study utilizing Eclipse V15.0
with AAA algorithm. Each patient will be planned with JT using the same collimator rotations
and number of arcs, and then re-computed with SJ as this method leaves unaltered the total
monitor units and efficiency of treatment.4 The static jaw plan will then be re-normalized for
comparable PTV54 coverage to within 1%. An OAR mean comparison of bladder, iliac crests,
and bowel will then be evaluated, in addition to maximum bowel doses. RTOG 0529 will be
used for guidance in planning and evaluation.
 References

1. Nicholas S, Chen L, Choflet A, et al. Pelvic radiation and normal tissue toxicity. J Semin
Radiat Oncol. 2017;27:358-369. http://dx.doi.org/10.1016/j.semradonc.2017.04.010
2. Pawlowski J, Jones WE III. Radiation Therapy For Anal Cancer. Treasure Island, FL:
StatPearls Publishing; 2020. https://www.ncbi.nlm.nih.gov/books/NBK537342/. Accessed
April 1, 2020.
3. Mohan R, Jayesh K, Joshi RC, Al-idrisi M, Narayanamurthy P, Majumdar, SD. Dosimetric
evaluation of 120-leaf multileaf collimator in a varian linear accelerator with 6-mv and 18-
mv photon beams. J Med Phys 2008; 33(3):114-118. http://dx.doi.org/10.4103/0971-
6203.42757
4. Wu H, Jiang F, Yue H, et al. A comparative study of identical vmat plans with and without
jaw tacking technique. J Appl Clin Med Phys. 2016; 17(5):133-141.
http://dx.doi.org/10.1120/jacmp.v17i5.6252
5. Yao S, Zhang Y, Chen T, et al. Dosimetric comparison between jaw tracking and no jaw
tracking in intensity-modulated radiation therapy. Cancer Res Treat. 2019; 18:1-6.
http://dx.doi.org/10.1177/1533033819841061
6. Feng Z, Wu H, Zhang Yi, Zhang Yu, Cheng J, Su X. Dosimetric comparison between jaw
tracking and static jaw techniques in intensity-modulated radiotherapy. Radiat Oncol. 2015;
10(28):1-7. http://dx.doi.org/10.1186/s13014-015-0329-4