capstone 2015

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1

Comparison of IMRT, VMAT, and 3D-CRT Treatment Techniques to Minimize Risk of

Radiation Induced Esophaitis for Mediastina! "#C$C% A Case #tud&

Authors: Brittany Check BS, R.T.(T), Jennifer Kouri BS, R.T.(T), Benjamin emieu! BS, R.T.

(T), "ishe#e enar$s, %S, C%&, R.T.(R)(T), 'AA%&, Ash#ey uneker, %S, C%&

A'stract%

Introduction% This stu$y aime$ to com*are eso*ha+ea# $ose usin+ three ra$iothera*y techniues

for me$iastina# non-sma## ce## #un+ cancer ("SCC) hi#e ana#yin+ a$euate tumor co/era+e

an$ #imite$ critica# structures $ose.

Case Description% The *resentation of 0u#ky, me$iastina# #un+ tumors are common#y associate$

ith "SCC. The treatment of me$iastina# #un+ cancer *resents cha##en+es $ue to the c#ose

*ro!imity of many sensiti/e critica# structures. &e*en$in+ on the tumor *ro!imity to the

eso*ha+us an$ tar+et $ose, *atients ho un$er+o chemora$iation for me$iastina# $isease may

*resent ith eso*ha+itis at some *oint $urin+ the course of treatment. Rose et a# su++este$ $ose-

/o#ume criteria that corre#ate ith the inci$ence of eso*ha+itis. 2n this stu$y, a *#an com*arison

of 3 $ifferent treatment techniues as con$ucte$ on 4 *atients $ia+nose$ ith "SCC of the

me$iastinum. 2ntensity mo$u#ate$ ra$iation thera*y (2%RT), /o#ume mo$u#ate$ arc thera*y

(5%AT), an$ 3& conforma# ra$iation thera*y (3&-CRT) ere com*are$ to ana#ye si+nificant

$ose-/o#ume criteria for the eso*ha+us hi#e maintainin+ a$euate tar+et co/era+e.

Conc!usion% 6ach *#an as e/a#uate$ for eso*ha+ea# $ose usin+ a $ose-/o#ume ana#ysis. The/o#ume of the eso*ha+us that recei/e$ 37 8y (537), 39 8y (539), 7 8y (57), 97 8y (597), an$

;7 8y (5;7) ere com*are$ for each treatment techniue. The mean $ose as a#so com*are$ to

$emonstrate the o/era## effecti/eness of the $ifferent treatment techniues on the $ose

$istri0ution to the or+an. The #oest eso*ha+ea# mean $oses ere o0ser/e$ in the 5%AT an$

2%RT *#ans at <7;=. c8y an$ <1<; c8y, res*ecti/e#y. The 3&-CRT mean eso*ha+ea# $ose as

<1.; c8y. The tota# *atient a/era+e of the $ose-/o#ume ana#ysis shoe$ that the 5%AT an$

2%RT *#ans ere near#y i$entica# e!ce*t for the 5;7, hich as =.13> an$ 1<.>, res*ecti/e#y.

The 3&-CRT a/era+e 5;7 as 14.4>. This stu$y shoe$ there are a$/anta+es to usin+ in/erse

*#annin+ techniues such as 5%AT an$ 2%RT for s*arin+ the eso*ha+us an$ an a$/anta+e of

usin+ 5%AT to 0etter contro# hi+her $oses to sma##er /o#umes of eso*ha+us.

(e& )ords: "SCC, eso*ha+itis, 2%RT, 5%AT, 3&-CRT

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Introduction

ifesty#es associate$ ith to0acco use, unhea#thy $iet, an$ inacti/ity increase the risk of

#un+ cancer? the most common ma#i+nancy in 0oth ma#es an$ fema#es or#$i$e. un+ cancer is

the #ea$in+ cause of cancer morta#ity ith unfa/ora0#e sur/i/a# rates after 9 years.1 2n <71<, 1 in

e/ery 9 cancer re#ate$ $eaths ere #inke$ to #un+ cancer.< @f a## #un+ cancers, =9> are

histo#o+ica##y $efine$ as "SCC.

The stan$ar$ of treatment care for "SCC reuires a hi+h $ose of ra$iation, *refera0#y

ith chemothera*y, for #oca# #on+-term contro#. 2t is +enera##y acce*ta0#e to $e#i/er ;7 to 49 8y

at 1.= to <.7 8y *er fraction o/er ; to 4 eeks for "SCC.1 &oses of ; 8y shoe$ +reater

#ocore+iona# contro# com*are$ to *atients recei/in+ #ess than ; 8y. 2f esca#ate$ another 17 8y,

#ocore+iona# contro# im*ro/e$ 0y 3;.>. A#thou+h this hi+h $ose re+imen increases *ro0a0i#ity

of e#iminatin+ $isease, the hi+h $ose to the *rimary $isease an$ in/o#/e$ #ym*h no$es increase

to!icities to the surroun$in+ critica# structures as e##. Since the tar+et /o#ume co/era+e takes

*riority o/er the surroun$in+ tissue to!icities, many me$iastina# structures $e/e#o* a$/erse si$e

effects.

A su0stantia# /o#ume of the eso*ha+us can 0e #ocate$ ithin the $esire$ tar+et /o#ume in

me$iastina# "SCC ra$iothera*y cases. 6!cessi/e eso*ha+ea# ra$iation e!*osure resu#ts in

eso*ha+itis. The inci$ence of acute eso*ha+itis /aries from 1.3> ith ra$iation a#one to 1> to

9<> ith concurrent chemora$iation thera*y. After recei/in+ 1= to 37 8y o/er a < to 3 eek

*erio$, sym*toms of $ys*ha+ia, heart0urn, an$ chest *ain can occur. 2f the eso*ha+us recei/es

more than 99 8y $e#i/ere$ to 3<> of the /o#ume, the risk an$ se/erity of eso*ha+itis esca#ates. 1,

ossi0#e #ate res*onses from se/ere eso*ha+itis inc#u$e eso*ha+ea# stricture in nee$ of

intermittent sur+ica# $i#atation, intra/enous hy$ration, or fee$in+ tu0e *#acement. A#thou+h $eath

from ra$iation-in$uce$ eso*ha+itis is se#$om, ua#ity of #ife $urin+ an$ after com*#etion of

treatment can resu#t in c#inica# an$ socia# im*airment.9

Bra$#ey et a#4 $emonstrate$ $osimetric *arameters corre#ate$ to the inci$ence of

eso*ha+itis. Research re/ea#s a hi+h $e+ree of /aria0i#ity re+ar$in+ the num0er of *atients, the

$ia+nosis an$ sta+e of the *atients, the *resence or a0sence of chemothera*y an$ sur+ery, an$ the

*rescri0e$ ra$iation $ose. oe/er, *atterns amon+ the stu$ies re#ate$ s*ecific $osimetric

*arameters to the rate of eso*ha+itis. 'or e!am*#e, the 597 an$ 5;7 ere the most common

in$icati/e factors of eso*ha+itis.;,4 There $oes not a**ear to 0e a s*ecific com*arison of

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treatment *#annin+ techniues re#atin+ the a0i#ity to #imit the $ose-/o#ume #e/e#s that are

corre#ate$ to eso*ha+itis.

%any treatment techniues ha/e 0een $e/e#o*e$ to he#* a/oi$ e!cessi/e $ose to critica#

structures throu+hout the 0o$y. 'or e!am*#e, 2%RT an$ 5%AT ha/e 0een essentia# in creatin+

*recise conforma# treatment *#ans. These in/erse treatment *#annin+ techniues a##o the

creation of /o#umetric a/oi$ances, in turn, mani*u#atin+ ra$iation $ose aay from critica#

structures an$ *ro/i$in+ +reater conformity ith *ossi0#e esca#ate$ $ose to the $e#ineate$ tar+et

/o#ume.1,= n#ike stan$ar$ 3&-CRT, 2%RT an$ 5%AT a##o for $ose esca#ation to the *rimary

tumor to increase #ocore+iona# contro# an$ im*ro/e$ thera*eutic ratio.=

The aim of this stu$y as to com*are three $ifferent ra$iothera*y treatment techniues

for 4 *atients ith me$iastina# "SCC hi#e ana#yin+ a$euate tumor co/era+e an$ #imite$

critica# structure $ose ith an em*hasis on eso*ha+ea# $ose s*arin+.

Case Description

Patient Selection & Setup

A tota# of 4 #oca##y a$/ance$ "SCC *atients ith me$iastina# #esions ere e/a#uate$

(Ta0#e 1). atients most common#y *resente$ ith chest *ain, cou+h, an$ $ifficu#ty 0reathin+. A##

*atients un$erent a CT simu#ation scan for ra$iation thera*y treatment. The *atients ere

*ositione$ su*ine, hea$ to +antry on the CT simu#ator couch. 'or re*ro$uci0i#ity, the *atients

ere immo0i#ie$ on a in+0oar$ an$ 5ac-ok ith 0oth arms e!ten$e$ a0o/e their hea$ an$

han$s *#ace$ ho#$in+ the T-0ar or *e+s. ar+e knee s*on+es ere uti#ie$ to ai$ in comfort. A 3-

*oint setu* as marke$ ith tattoo ink or *aint markers on the chest for #aser *ositionin+ *rior to

$ai#y treatment. Three of the 4 *atients ere scanne$ ith & techniue to e/a#uate the nee$ for

res*iratory +atin+. 2n of the *atients, *hysicians *#ace$ the simu#ation isocenter on *#annin+ CT

scans. The other 3 *atients ha$ ra$io*aue references markers *#ace$ an$ the isocenter as set

$urin+ treatment *#annin+.

Target Delineation

After simu#ation, the CT scans ere im*orte$ to %2% softare or 6c#i*se Treatment

#annin+ System (TS) for fusion. &ia+nostic 6T-CT scans an$ CT ima+es ere fuse$ to+ether

to faci#itate in the $e#ineation of the +ross tumor /o#ume (8T5). The 8T5 consiste$ of the

*rimary tumor an$ metastatic #ym*ha$eno*athy, as seen meta0o#ica##y hi+h#i+hte$ on the 6T-

CT. A mar+in as *#ace$ aroun$ the 8T5 to $efine the c#inica# tar+et /o#ume (CT5). The CT5

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encom*asse$ su0-c#inica# $isease uns*ecifie$ on the ima+in+ mo$a#ity. To $efine a## *ossi0#e

+eometrica# /ariations an$ inaccuracies, a mar+in of 1 cm as *#ace$ aroun$ the CT5 to

$e#ineate the *#annin+ tar+et /o#ume (T5). The e!*ansion of the tar+et /o#umes incor*orate$

*resume$ microsco*ic e!tension an$ res*iratory motion. &e*en$in+ u*on *hysician *reference,

the 8T5 as not e!*an$e$ into a CT5, on#y a T5. To e/a#uate an$ recor$ $ose attenuate$ 0y

the or+ans at risk (@R) $urin+ treatment, the me$ica# $osimetrists contoure$ the ri+ht an$ #eft

#un+, the tota# #un+ minus the T5, heart, carina, an$ s*ina# cor$. The #i/er an$ 0rachia# *#e!us

ere a#so contoure$ on some *atients. Contours ere $ran accor$in+ to the Ra$iation Thera*y

@nco#o+y 8rou* (RT@8) 117; Thoracic At#as. To account for uncertainties, the s*ina# cor$ as

e!*an$e$ ith a mar+in of 7.9 cm to create a *#annin+ or+an at risk /o#ume (R5) for some

*atients. The eso*ha+us as contoure$ from the cricoi$ to the +astroeso*ha+ea# junction.

Treatment Planning

To e/a#uate the $ose to the eso*ha+us, 3 $ifferent ra$iothera*y *#annin+ techniues ere

create$ *er *atient case. The +oa# of the treatment *#annin+ as to create the most o*tima# *#an

*er *atient case hi#e tryin+ to minimie eso*ha+ea# $ose. As a resu#t, the fie#$s ere

customie$ *er *atient case. 6ach case as *rescri0e$ a tota# $ose of ;7 8y in 37 fractions to the

T5. To achie/e co/era+e, a## *#ans ere norma#ie$ to isocenter or a ca#cu#ation *oint so that

177> of the $ose as recei/e$ to 9> of the tar+et /o#ume. @n#y ; %5 0eam ener+ies ere

use$ for treatment *#annin+. etero+eneity corrections ere a**#ie$ to a## the *#ans. Ca#cu#ations

ere com*#ete$ ith the ana#ytica# anisotro*ic a#+orithm (AAA) im*#emente$ in 6c#i*se TS.

The 0eam arran+ement for 2%RT *#ans as chosen to o*tima##y co/er the T5 hi#e

#imitin+ @R $oses. Beteen 9 an$ 4 fie#$s ere use$ $e*en$in+ on the #ocation of the tumor an$

@R (Ta0#e <). 2n 9 of the 4 cases, 4 e/en#y $istri0ute$ fie#$s ere use$ to a/oi$ *ara##e# o**ose$

fie#$s sharin+ the same f#uence ma*. ost-*rocess structures ere create$ *rior to o*timiation

for 2%RT *#ans. @0jecti/es ere set for the T5 or T5 o*timiation structures to recei/e 177>

or more of the *rescri0e$ $ose. @0jecti/es ere a#so set to T5 structures to *re/ent $oses 3->

hi+her than the *rescri*tion. A 1 cm rin+ as create$ surroun$in+ the T5 ith a 7 to < mm +a*

0eteen the rin+ an$ the T5. An u**er o0jecti/e as set for the rin+ structure to re$uce hi+h

$oses outsi$e the T5. 'or structures that o/er#a**e$ the T5, such as the heart in some cases,

an a/oi$ance structure as create$ after cro**in+ the structure 7.9 cm aay from the T5.

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&urin+ o*timiation, hi+her *riority as +i/en to the T5 structures than @R o0jecti/es. "orma#

tissue o0jecti/e *arameters ere set $e*en$in+ on the nee$s of each case.

ike 2%RT *#ans, *ost-*rocess structures ere create$ *rior to o*timiation for 5%AT

*#ans. Arc +eometry /arie$ $e*en$in+ on the #ocation of the tumor an$ surroun$in+ critica#

structures. Sto* an$ start an+#es are shon in Ta0#e <. The o*timiation o0jecti/es ere set in a

simi#ar manner as the 2%RT o0jecti/es. "orma# tissue o0jecti/es ere esta0#ishe$ *er *atient

case.

"o a$$itiona# contourin+ as nee$e$ for 3&-CRT *#annin+. A 0#ock mar+in of 7.9 cm to

1.3 cm as *#ace$ aroun$ the T5 for *ro*er co/era+e. The majority of the cases ere *#anne$

ith 3 fie#$s consistin+ of an anterior, *osterior, an$ #atera# 0eam. ess ei+htin+ as +i/en to

the #atera# fie#$. A co*#anar 0eam arran+ement of 9 to ; 0eams as use$ for 3 of the 4 *atients.

Ta0#e < $is*#ays the 0eam orientation use$ for *#annin+. e$+es an$ se+mente$ fie#$s ere

uti#ie$ hen necessary to achie/e a homo+eneous $ose $istri0ution.

Plan Analysis & Evaluation

6so*ha+ea# $ose com*arisons ere ma$e from a $ose-/o#ume ana#ysis for each of the 3

treatment *#annin+ techniues ('i+ure 3 an$ Ta0#e 3). 'ocus as *#ace$ on the /o#ume of the

eso*ha+us recei/in+ 37 to ;7 8y since e/i$ence su++ests that these *arameters may inf#uence the

rate an$ +ra$e of ra$iation-in$uce$ eso*ha+itis. The most common *re$icti/e factors ere foun$

to 0e the 597 an$ the 5;7;,4,. The 537,539, an$ 57

ere a#so foun$ to 0e corre#ate$ ith

eso*ha+itis.;,,17 The mean as a#so com*are$ to $emonstrate o/era## $ifferences in eso*ha+us

$ose for each techniue. 2n the 4 *atients stu$ie$, the mean 597 as 31.>, <7.3>, an$ <7.<>,

for 3&-CRT, 2%RT, an$ 5%AT, res*ecti/e#y. Therefore, 5%AT resu#te$ in simi#ar outcome as

2%RT, an$ a 39.4> $ecrease in the /o#ume of eso*ha+us irra$iate$ ith 97 8y com*are$ to 3&-

CRT. The mean 5;7 as 14.4>, 1<.>, an$ =.1> for 3&-CRT, 2%RT, an$ 5%AT, res*ecti/e#y.

Simi#ar#y, 5%AT resu#te$ in 3.4> $ecrease com*are$ to 2%RT, an$ a 9.<> $ecrease

com*are$ to 3&-CRT. 2so$ose com*arison an$ $ose /o#ume histo+ram (&5) com*arison for

one *atient can 0e seen in 'i+ures 1 an$ <.

S#i+ht /ariation as o0ser/e$ 0eteen the iso$ose $istri0utions for 2%RT an$ 5%AT,

thou+h 0oth $iffere$ from 3&-CRT. The cha##en+e $urin+ 3&-CRT *#annin+ as minimiin+ the

ma!imum $ose to a to#era0#e #e/e#. Since the tumors ere 0u#ky in sie more 0eams ere nee$e$

for co/era+e. 2t as o0ser/e$ that more 0eams increase$ the /o#ume of hea#thy #un+ tissue

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recei/in+ ra$iation.

hi#e the eso*ha+us cannot 0e remo/e$ from a me$iastina# treatment fie#$,

the $ose can 0e a#tere$ $e*en$in+ u*on hich treatment techniue is use$.

An im*ortant $ifference 0eteen 0oth 2%RT an$ 5%AT in com*arison to 3&-CRT is the

tar+et $ose conformity. @ften times, me$iastina# "SCC T5s may inc#u$e or a0ut a *ortion of

the eso*ha+us. By increasin+ the conformity of the *rescri*tion $ose 0y usin+ 2%RT or 5%AT, a

#oer /o#ume of the eso*ha+us recei/es a hi+h $ose. A#thou+h increasin+ the num0er of 0eams

or arcs he#*s to achie/e conformity, it may a#so increase the s*rea$ of #o $ose to a +reater

/o#ume of the 0o$y.

Conc!usion

Current#y, the stan$ar$ of care for "SCC reuires a $ose of ;7 to 49 8y hich can

cause trou0#esome si$e effects for *atients. The eso*ha+us is often in c#ose *ro!imity or inc#u$e$

in the T5 for *atients ith me$iastina# "SCC resu#tin+ in eso*ha+itis hich si+nificant#y

affects ua#ity of #ife. To re$uce the si$e effects to the eso*ha+us, $oses shou#$ 0e monitore$ an$

minimie$ $urin+ the treatment *#annin+ *rocess. Stu$ies su++est that eso*ha+ea# $ose-/o#umes

most c#ose#y #inke$ to eso*ha+itis are the 597 an$ 5;7.;,4 This case stu$y as con$ucte$ to

e/a#uate the inf#uence of treatment *#annin+ techniues on the eso*ha+ea# $ose-/o#ume

*arameters associate$ ith eso*ha+itis.

2n this case stu$y of 4 *atients, the /o#ume of eso*ha+us recei/in+ 37 8y to ;7 8y for

2%RT, 5%AT, an$ 3&-CRT as e/a#uate$. The 2%RT an$ 5%AT *#ans *ro$uce$ the most

fa/ora0#e resu#ts ith eso*ha+us $ose-/o#umes #oer than that of 3&-CRT. The most su0stantia#

$ifference in eso*ha+ea# /o#ume 0eteen 2%RT, 5%AT, an$ 3&-CRT as seen in $oses 7 8y

to ;7 8y. Bra$#ey et a#4 $emonstrate$ that 2%RT, hen com*are$ to 3&-CRT, ha$ a si+nificant

a$/anta+e to sha*e $ose $istri0utions aroun$ critica# tissues an$ $ecrease to!icity to the

eso*ha+us a##oin+ for $ose esca#ation? hoe/er, the stu$y $i$ not inc#u$e 5%AT. 2n the current

case stu$y, it is e/i$ent throu+h iso$ose *#an com*arison that su*erior $ose conformity an$

homo+eneity a**ear to contri0ute to the re#ati/e s*arin+ of the eso*ha+us in 2%RT an$ 5%AT

*#ans. To a sma##er $e+ree, 5%AT a**eare$ to re$uce the /o#ume of eso*ha+us treate$ more

effecti/e#y than 2%RT. The si+nificance of this stu$y as to $emonstrate ho treatment *#annin+

techniues affect the meanin+fu# eso*ha+us $ose in *#ans that re$uce the risk of eso*ha+itis an$

increase the *atient ua#ity of #ife.

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2n a$$ition to eso*ha+itis, minimiin+ hea#thy #un+, heart, or s*ina# cor$ $ose may 0e

most im*ortant $e*en$in+ on each *atientDs situation an$ comor0i$ities hen se#ectin+ a

treatment techniue for "SCC. sin+ 2%RT or 5%AT may a#so ha/e *otentia# $ra0acks such

as s*rea$in+ #o $ose o/er hi+h /o#umes of hea#thy tissue, an$ *otentia##y usin+ a +reater

uantity of monitor units (%). imitations of this stu$y inc#u$e the sma## num0er of *atients

stu$ie$ an$ the uti#iation of $ose-/o#ume $ata corre#ate$ to eso*ha+itis rather than 0io#o+ica#

effect or actua# *atient outcomes. 'urther stu$ies are nee$e$ to in/esti+ate the eso*ha+ea# $ose

$ifferences in 3&-CRT, 2%RT, an$ 5%AT for a #ar+er *o*u#ation of *atients or usin+ $ifferent

o*timiation metho$s.

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