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5 Volumetric Modulated Arc Therapy

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V. Dumane et al.

Moreover, with reduced MU, there is also a decrease in total body exposure due

to leakage radiation. Unlike static field IMRT, where radiation is delivered from

a fixed number of gantry angles, it is delivered continuously over an arc range

with VMAT. The intensity of the beam in VMAT is modulated as a function of

gantry angle, MLC speed, and the dose rate of the linear accelerator (LINAC).

Treatment can be delivered within 1–3 arcs of rotation, with each arc taking

under 2 min to deliver. Although the concept of VMAT was first described in

1995 [25], its commercial implementation has only taken place within the past

decade. The application of VMAT for locoregional radiotherapy of left-sided

breast cancer is relatively new [26]. PTV and OAR contours are the same as in

multibeam IMRT. The angle at which the largest separation of the PTV is projected in the beam’s eye view (BEV) is chosen. The largest separation often

tends to be >15 cm. Due to limitations on the MLC leaf travel within an individual field (which is a maximum of 15 cm on certain linear accelerators), the

PTV needs to be covered by a minimum of two fields as shown in Fig. 7.10a. To

allow for a smooth transition of dose, the fields overlap at the isocenter by 2 cm.

The collimator angle is set to 0°. Each field is an arc whose range is around

190–220° similar to 11-field IMRT as shown in Fig. 7.10b. Both arcs are simultaneously optimized. In the optimizer, the gantry motion is modeled as a number

of discrete angular segments and the MLC aperture/shape for each segment is

optimally determined for each gantry angle. Variables that are controlled to optimally determine these apertures are the dose rate, the speed of the MLC leaves,

as well as the speed of the gantry. VMAT can achieve similar PTV coverage and

sparing of organs at risk with a much shorter delivery time and MU compared to

IMRT [26]. Figure 7.11 shows a comparison of the dose distribution with

11-field IMRT versus 2-arc VMAT for a left-sided breast cancer patient receiving regional nodal radiation. The monitor units (MU) required for delivery with



Fig. 7.10 (a) Beam’s eye view of the two treatment fields with a 2-cm overlap. These two fields

together cover the volume-rendered PTV that combines the breast/chest wall along with all the

regional nodes. (b) Two partial VMAT arcs of sector angle range 190–220°. One arc rotates clockwise and the second arc rotates counterclockwise


Intensity-Modulated Radiation Therapy for Breast Cancer


Fig. 7.11 Comparison of the dose distribution with 11-field IMRT in the axial, coronal, and

sagittal planes on the left side versus 2-arc VMAT for the same case requiring regional nodal


VMAT are approximately one-third of that required for IMRT. The reduced MU

and number of treatment fields contribute toward a faster treatment delivery with

VMAT, which enables the utilization of this modality with respiratory gating


There are additional considerations when choosing between IMRT and

VMAT. In cases where RNI is performed, it is necessary to accommodate for variation in treatment due to setup uncertainty and patient breathing and for swelling

of breast tissue during treatment. In IMRT planning, the uncertainties introduced

by these variations can be overcome by extending the optimal fluence outside the

body contour after optimization is completed. Certain treatment planning systems

offer a tool referred to as the “skin flash” tool that allows this extension to accommodate for these uncertainties. VMAT planning, however, does not allow the

accommodation for skin flash to account for any of these uncertainties. Although

the use of artificial bolus in the optimization process would in theory allow for

movement of the breast/chest wall during treatment and has been discussed [26],

the actual implementation of this technique has not yet been validated. Given the

inability of VMAT to accommodate for skin flash, VMAT use is limited to unreconstructed patients or patients with implants or tissue expanders at MSKCC,

under the assumption that the degree of swelling would be minimal in patients with

breast prostheses or absence of reconstructions, compared to patients with intact

breast tissue.

The position of the ipsilateral arm of the patient during treatment can show considerable variation between fractions, as illustrated in Fig. 7.12. Because this can

significantly impact the accuracy of dose delivery [27], arm avoidance (AA) VMAT

planning technique has been developed at MSKCC [28]. Figure 7.13 shows the

details of the field arrangement with AA VMAT.



V. Dumane et al.


Fig. 7.12 Treatment arm position variation between patients and treatment sections. (a) Overlay

of 5 surface models which have smaller variation. (b) Overlay of 15 surface models which have

larger variation. Both patients were immobilized in a Civco® breast board

Fig. 7.13 Example of arc geometry for arm avoidance VMAT planning. Two long arcs (Arc1 and

Arc2) mainly in the anterior direction and avoiding entering the ipsilateral arm cover the supraclavicular part and medial chest wall part of the PTV. Two shorter arcs (Arc3 and Arc4) inferior of the

ipsilateral arm and extending posteriorly cover the chest wall part of the PTV


Deep Inspiration Breath Hold (DIBH) with VMAT

Compared to conventional planning for RNI, both VMAT and IMRT have demonstrated the advantage in reducing volume of the heart covered by high doses, namely,

the V20 Gy and V40 Gy [7, 26]. However, both these techniques still expose a higher


Intensity-Modulated Radiation Therapy for Breast Cancer


volume of surrounding normal tissue to low dose levels, such as V05 Gy. In addition,

the MHD is a parameter of heart dose that clinicians and dosimetrists both strive to

minimize to the lowest value possible. Deep inspiration breath hold (DIBH) is a

technique that has been applied to maximize the distance between the chest wall and

heart allowing for adequate treatment of the breast and underlying chest wall while

minimizing irradiated cardiac volume (see Chap. 6) [29]. Combining IMRT with

DIBH can therefore potentially provide a cumulative benefit in reduction of MHD

and V05 of the lungs for this group of patients. The implementation of breath-hold

techniques with multibeam IMRT is impractical, since it would considerably prolong the treatment delivery if a patient were to hold her breath with every field.

VMAT, however, due to its shortened delivery time, enables the integration of breathhold techniques. At MSKCC, DIBH has been utilized in breast cancer patients

receiving left-sided comprehensive RNI with VMAT. In a study of 10 patients receiving left-sided RNI, a combination of VMAT and DIBH reduced MHD on average by

3 Gy but also helped to reduce the volumes of the heart and lung covered with 5 Gy

isodose line by as much as 30 %, compared to free-breathing DIBH plans performed

on the same patients [30]. Hence, the use of DIBH is strongly recommended as an

adjunct modality to VMAT when treating left-sided breast cancer patients requiring




The radiotherapy treatment planning process starts at the time of simulation, where

the patient position is set to the anticipated position for treatment planning. The

rule of thumb for patient positioning includes (1) easy access by radiation beams

without passing through unnecessary normal tissue or causing collision with the

gantry, couch, or patient, (2) a comfortable position with an immobilization device

that enables the patient to lie still in supine position during treatment, and (3) a

reproducible approach with body tattoos, body-couch index, and image guidance to

facilitate patient setup at treatments. A three-dimensional (3D) computed tomography (CT) image of a patient at the treatment position will be acquired, which is

essential for IMRT planning. Additional imaging modalities may be prescribed and

acquired to enhance the visualization of a tumor and surrounding normal tissues

and to facilitate tumor delineation and localization, including positron emission

tomography (PET)/CT, magnetic resonance imaging (MRI), or respiratory-correlated 4DCT images.

Simulation for breast IMRT treatment requires that the patient lies in supine

position on a breast board or a body mold, with the torso tilted upward with 5–10°

and both arms up. Unlike simulations for conventional 3DCRT where the head can

be tilted contralaterally away from the treatment side, the head position is straight

for IMRT simulations to ensure reproducibility. A clinician places wire markers

around the breast or implant and on the surgical scar. Intravenous contrast may be

used at the discretion of the MD in order to better visualize the nodal regions and/or

coronary vasculature. Patient alignment is checked with scout radiograph images,

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