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THE UNIVERSITY OF OKLAHOMA

A Comparison of 3-D conformal, IMRT, and VMAT for Treatment of Prostate Cancer


Curtis Wilgenbusch, RT(T)(CT)(QM), CMD
The University of Oklahoma
Health Sciences Center
4/19/2013





2

A Comparison of 3-D conformal, IMRT, and VMAT for Treatment of Prostate Cancer

Abstract
The treatment of prostate cancer has been commonly performed with external beam radiation
for several decades. Prostate cancer is a common cancer in men and is well controlled with high doses
of radiation. These high doses are limited by the critical normal structures that are in close proximity to
the prostate and seminal vesicles. Intensity-modulated radiation therapy (IMRT) has become the
standard of care for patients with both intermediate and high-risk prostate cancer because it has the
ability to deliver high doses of radiation to the target while keeping the doses to the organs at risk (OAR)
relatively low. This literature review is done in an attempt to compare a novel treatment technique
known as volumetric-modulated arc therapy (VMAT) to other common treatment techniques such as 3-
D conformal and IMRT. The results of the review show that both IMRT and VMAT plans are a significant
improvement over 3-D conformal, while the main advantage of VMAT is its high treatment efficiency
when compared with the other options.
Introduction
It is estimated that there will be 240 890 new cases of prostate cancer in 2011, which is the
highest of any other cancer in men.
1
It is also estimated that there will be 33 720 deaths related to
prostate cancer, which is second only to lung and bronchus cancers.
1
High doses of radiation are
necessary for local disease control and there has been a high success rate with external beam radiation
therapy. When 3-D conformal therapy was introduced, it was used successfully to deliver high doses of
radiation to the target but fell short when attempting to limit the doses delivered to the organs at risk
(OARs) such as the bladder, femoral heads, small bowel, and rectum.
3

When intensity-modulated radiation therapy ( IMRT) was introduced in the 1990s, it allowed
radiation oncologists to reduce the doses to these critical structures while maintaining a high dose of
radiation to the target.
2
There are some downsides to IMRT however. First, the length of time that it
takes to deliver the complete treatment for several static fields, typically 7-9 fields, can become very
long. This can be problematic because it allows more time for the target to move around during
treatment (i.e. intrafraction motion). Intrafraction motion increases the likelihood of missing parts of the
target and treating more of the critical structures. The extended periods of time used to treat these
patients also reduces patient throughput.

Second, IMRT generally uses a high amount of monitor units
in an attempt to modulate the dose delivered to the target and maintain doses to OARs at an
acceptable level. This increase in monitor units allows more scatter radiation to reach the patient and is
of concern when considering the possibility of secondary malignancies. The risk of secondary
malignancies due to scatter radiation is not completely known and requires further investigation and
research.
The goal of this review is to compare a novel treatment technique known as volumetric-
modulated arc therapy (VMAT) to 3-D conformal and IMRT. When VMAT, which is a modification of an
older arc technique, was introduced in 2007, it allowed beam modulation at different intervals during an
arc of up to 360.
2
This allows treatment times to be dramatically reduced but also allows the doses to
OARs to be kept low and the doses to the targets kept high and conformal. At the same time, VMAT
plans keep the monitor units relatively low, which reduces the scattered radiation to the patient.
Methods
Pertinent articles on relevant treatment techniques for prostate cancer were located by
performing an online search of electronic journal and some were found upon review of the reference
section of these articles. Several articles were found that included studies that analyzed treatment
4

plans of patients treated for prostate cancer. Each article was fully analyzed and the results were
divided into categories that compared plan qualities for 3-D conformal, IMRT, and VMAT. For each
treatment technique results were further divided into categories that compared target coverage, dose
to the OARs, total treatment time, and total monitor units.
3-D Conformal
Procedure
In order for a 3-D conformal plan to be designed, the patient must have an initial treatment
planning computed tomography/simulation (CT/SIM) completed. This involves setting the patient in
their treatment position using an immobilization device. In the case of prostate cancer patients in this
study, all were treated in the supine position with their legs in a cradle specifically made for them.
When the planning CT is complete, the radiation oncologist contours the target volumes using the
treatment planning software. In some cases, the radiation oncologist fuses a diagnostic positron
emission tomography (PET)/ CT or magnetic resonance imaging (MRI) with the treatment planning CT in
order to better define the target or targets.
After the target volumes are outlined by the physician, the treatment plan can be designed with
the goal of having sufficient coverage of the target volumes while trying to spare the normal tissue in
the beams path. The planner strategically chooses beam paths or angles based on the patients
anatomy and the treatment planning software computes the dose distribution and iteratively changes
the beam weighting to adjust the target coverage and reduce the dose to the OARs as much as possible.
Typically, 4-6 fields are used depending on the goal of treatment and the complexity of the target
volumes.
Target Coverage
5

The 3-D conformal plans in the studies reviewed were able to achieve excellent target coverage
(Table 1). In a study by Wolff et al, the 3-D conformal plans had 99% of the target covered by an average
of 71.020.58 with a prescribed dose of 76 Gy.
3
In a study by Sale et al, the conformal plans had 95% of
the PTV covered by a mean of 75.88 Gy with a prescribed total dose of 75.6 Gy.
4
In a study done by
Palma et al, the conformality index (i.e. the volume of 95%/PTV) was 1.36, although this statistic can be
a little deceiving because it does not guarantee that both volumes actually overlap.
5
Dose to Organs at Risk (OAR)
The OARs for treatment of prostate cancer are typically the small bowel, bladder, rectum, and
the left and right femoral heads. Generally, when using 3-D conformal treatment techniques, only a
small number of fields are used and there is not a lot of beam modulation. This delivers high doses to
normal tissue in order to achieve better target coverage (Table 2). The problem with elevated doses to
the normal tissues is the resulting side effects. There are both early and late effects that depend on the
type of tissue irradiated, the dose delivered, and the total volume that is irradiated.
In a study by Wolff et al, the anterior and posterior rectum were both exposed to high doses in
the conformal plans .
3
The mean dose to the posterior rectum was 55.43 Gy in their conformal plans.
3
In
the study by Palma et al, the 3-D conformal plans were unable to meet the dose constraints.

The
percentage of rectum receiving 40 Gy was 66.8% with a goal of 25%.
5
Part of the reason that these
plans were unable to meet these constraints was due to the fact that the objectives were purposely
made stricter for the IMRT and VMAT plans. The conformal plans inabilities to modulate the beam could
explain shortcoming in these results. The study by Sale et al showed that the rectum V40 was 66.01%
and the rectum V75 was 23.95%.
5
In that study, the maximum bladder dose was 59.34 Gy, the
maximum dose to the right femoral head was 63.30 Gy, the maximum dose to the left femoral head was
63.60 Gy, and the maximum dose to the small bowel was 40.95 Gy.
4
6

Total Treatment Time
Total treatment time is defined as the time it takes to deliver the treatment once image-
guidance has been performed. This is dependent on the amount of beams used and the monitor units
required to deliver the dose to the target per field. Treatment time impacts both patient comfort and
physiologic motion (i.e. bladder and rectal filling) and affects patient throughput. One of the major
concerns with extended treatment time is the fact that the target position may vary greatly during
treatment (i.e. intrafraction motion). This, in turn, can impact the planning target volume (PTV) which
takes into account different variables such as daily setup errors and patient motion. If these factors can
be minimized, then the PTV can be reduced which will further reduce the doses to the OARs.
In the study by Wolff et al, the average total treatment time was 2.50.1 minutes for the 3-D
conformal plans.
3
The other studies included a comparison of monitor units but not for treatment
times. Monitor units have an impact on treatment times but does not define them. Other factors that
affect total treatment time include the number of beam angles used, the dose rate, and the speed of the
gantry.
Total Monitor Units
One major advantage of 3-D conformal radiation therapy is the fact that it generally requires
relatively few monitor units (Table 3). This is the general consensus of all the studies compared in this
review. The main reason for this is no beam modulation, unless wedges are used. This translates into
shorter total treatment times as well as less scatter radiation, and a lower integral dose to the patient,
which reduced the risk of secondary malignancies.

7

In the study by Wolf et al, the average total monitor units were 2528 for 3-D conformal.
3
In the
study by Palma et al, the mean total monitor units was 295.5.
5
In the study by Kry et al., the mean
monitor units were 233 and the maximal monitor units were 254.
6
Intensity-Modulated Radiation Therapy (IMRT)
Procedure
Intensity-modulated radiation therapy requires a CT scan that is used for treatment planning.
As with the 3-D conformal procedure, the patient is set up in the treatment position utilizing
immobilization devices. The physician outlines the target volumes and a plan is created using the
treatment planning software. The planner enters the beam angles and the photon energies and the
treatment planning system iteratively finds the optimal beam weights and control points. The main
benefit of inverse treatment planning is the ability of the treatment planning optimizer to come up with
the optimal beam intensities to deliver the target doses while keeping the doses to the OARs as low as
possible.
Target Coverage
Intensity-modulated radiation therapy (IMRT) has been used with the intent of treating target
volumes with concave shapes. This technique makes it easy to form the prescribed dose to oddly
shaped targets that are in close proximity to critical structures or even wrapped around critical normal
organs. This allows clinicians to use dose escalation while sparing normal tissues, which is critical for
delivering a tumoricidal dose while maintaining an acceptable dose to the OARs. This technique has
become the standard of care for prostate cancer patients treated with a curative intent. When this
technique is combined with image guidance it delivers excellent results in tumor control and sparing of
organs.
3


8

The IMRT plans in the studies evaluated were able to achieve the initial planning goals set forth
by the radiation oncologist and planner (Table 1). In the study by Wolff et al, the dose to 99% of the
PTV was 66.461.9 Gy with a prescribed dose of 76 Gy.
3
The study by Sale et al., the mean dose to 95%
of the PTV was 76.10 with a prescribed dose of 75.6 Gy.
4
In the study by Kopp et al., the plans had an
average of 99.33% of the PTV covered by the total dose which was 77.40 Gy.
7
The study by Afghan et al.
showed that the volume of the PTV covered by 95% of the prescribed dose was 96.7%.
8
Dose to Organs at Risk (OAR)
The dose to the OAR is significantly decreased with the use of IMRT when compared with
traditional 3-D conformal techniques (Table 2). Even if there are beams that pass directly through OARs
on their path to the target, the treatment planning optimizer will find the best possible beam weighing
and control points in order to deliver the right amount of dose to the target while minimizing the dose
to the OAR. One way to improve the target dose and reduce the dose to the OAR is to increase the
amount of non-opposing fields. This gives the optimizer more options when it comes to sparing the OAR
and increasing the dose to the target or targets.
In the study by Wolf et al, the mean dose to the rectum is 34.891.81 Gy with the IMRT plan.
3

In the study by Palma et al, the volume of rectum receiving 40 Gy was only 17.1% with IMRT.
5
The
volume of bladder receiving 40 Gy in their study was only 26.7% with IMRT.
5
The study by Sale et al
showed that the dose to the rectum was 48.89% receiving 40 Gy with IMRT.
4
In the study by Kopp et al.,
25% of the bladder received 52.13 Gy and 25% of the rectum received 40.68 Gy.
7
In the study by Afghan
et al., the mean dose to the bladder was 81.3 Gy and the mean dose to the rectum was 79.5 Gy.
8
Total Treatment Time
9

In the study by Wolff et al, the total treatment time was 6 minutes with IMRT.
3
The study by
Palma et al only claims that the increase in monitor units from 3-D to IMRT increases the total beam on
time.
5
In the study by Afghan et al., the average treatment times for the fixed-field IMRT plans was 7
minutes and 33 seconds.
8
In the study by Tsai et al., the treatment time for step-and-shoot IMRT was
3.80.3 minutes.
9
Total Monitor Units
The fact that IMRT uses many control points in order to control the dose delivered per beam to
the OAR and targets causes the monitor units to increase dramatically (Table 3). Even though this is a
benefit to the patient as far as controlling the dose delivered to the OAR, it is a disadvantage in that it
causes more scatter radiation to reach the patient. This has been said to increase the chances of the
patient acquiring a secondary malignancy due to the increased exposure to ionizing radiation.
In the study by Wolf et al, the total monitor units were 544 for the IMRT plans.
3
The study by
Palma et al, showed an average of 788.8 monitor units for IMRT plans.
5
The study by Tsai et al showed
an average of 336.116.8 for the IMRT plans.
9
The study by Afghan et al showed that the average
monitor units were 621 for the IMRT plans.
8
Volumetric-Modulated Arc Therapy (VMAT)
Procedure
Volumetric-modulated arc therapy is a relatively new technique. It is an improvement on an
older arc technique in which the arcs were delivered with uniform intensity. This new technique utilizes
more advanced technology in which the arcs are delivered using variable dose rates and/or variable
gantry speeds. Yu et al described this new technique that they called intensity-modulated arc therapy in
1995.
11
They claimed that by delivering the radiotherapy in an arc fashion, one could hypothetically
10

deliver an unlimited number of beams from many different angles. This should increase the
conformality of the dose distributions while spreading the dose to areas of less concern. The treatment
planning requirements are similar to those of IMRT. A treatment planning CT is required with the
patient immobilized in a leg cradle. The radiation oncologist must draw the target volumes on the CT
data set, sometimes with the assistance of fused MRI or PET/CT images. The planner inputs the
treatment planning objectives into the treatment planning software. The software then optimizes the
dose delivered through the full rotation of the arc.
Target Coverage
The VMAT plans in the studies reviewed were able to achieve similar results to the IMRT plans
(Table I). In the study by Wolff et al, the average dose from the VMAT plans to 95% of the target was
71.59 Gy with a prescribed dose of 76 Gy.
3
The study by Sale et al showed that 95% of the PTV received
75.89 with a prescribed dose of 75.6 Gy for the VMAT plans.
4
The study by Quan et al only states that
the PTV coverage was similar for both IMRT and VMAT plans.
10
They based this on the comparison of
dose-volume histograms from each type of plan. In the study by Afghan et al, the volume covered by
95% of the target dose was 98.9%.
8
Dose to Organs at Risk (OAR)
The VMAT plans in the studies reviewed achieved excellent results (Table 2). The study by Wolff
et al stated that the dose to the posterior rectum was 38.57.
3
The study by Sale et al showed that the
volume receiving 75 Gy was 12.04% for VMAT and showed a large reduction in the dose to the right
femoral head
4
. Only 21.58% received 30 Gy from the VMAT plans.
4
The study by Kopp et al showed that
25% of the bladder received 48.15 Gy and 25% of the rectum received 57.10 Gy
7
, while the study by
Afghan et al showed that the mean dose to the bladder was 82.1 Gy and the mean dose to the rectum
was 80.8 Gy.
8
11

Total Treatment Time
The study by Wolff et al showed that the total treatment time was an average of 1.8 minutes
with VMAT.
3
The study by Palma et al only stated that the reduction in monitor units was great (i.e.
38%), which has implications in reducing the total treatment time especially since the monitor units
from the VMAT plans are delivered continuously instead of having to change the gantry position
between each field which increases the total treatment time.
2
Total Monitor Units
The monitor units were relatively low with the VMAT plans (Table 3). In the study by Wolff et al,
the total monitor units were an average of 386 for the VMAT plans.
3
The study by Palma et al, showed
that there was a 38% relative reduction in the mean number of monitor units from the IMRT plans to
the VMAT plans.
5
In the study by Quan et al, only IMRT and VMAT plans were compared but showed
that the VMAT plans used about 30% more total MUs that the 8-beam IMRT plans, but were only 4%
more than the 24-beam IMRT plans.
10
The study by Quan et al used Pinnacle and they believed that the
result in higher MUs for the VMAT plan may be due to the superior conformality and organ sparing
achieved with the VMAT plans vs. the IMRT plans. In a study by Tsai et al, the mean MUs for the VMAT
plans were only 309.7.
9
The average monitor units used in the study by Afghan et al was 536.
8
Discussion
Volumetric-modulated arc therapy has recently become a popular option in the treatment of
prostate cancer. For the past 10 years or more, IMRT has been the gold standard in the treatment of
prostate cancer. The reason for IMRTs popularity is due to its ability to deliver high doses of radiation
to the prostate while keeping the dose to the OARs low. Before the time of IMRT, 3-D conformal did a
great job of delivering a high dose to the target volumes but failed when it came to the doses delivered
12

to the OARs.
This literature review has revealed that VMAT has done a good job covering the target volumes
and keeping the doses to the OARs as low as those with IMRT. Target coverage is typically better with 3-
D conformal than both IMRT and VMAT in all studies that were compared. The reason for this is that
fewer beams are used and the coverage is much less conformal than with both the IMRT and VMAT
plans. The problem with this is that more normal tissue receives a higher dose, especially the rectum,
which causes more of both early and late complications such as diarrhea and rectal bleeding
respectively.
Most of the studies reviewed showed that IMRT still does a better job at keeping the doses to
the rectum a little lower but the doses delivered by VMAT are well within the set objectives. All of the
studies compared were in agreement that the change from 3-D conformal to IMRT dramatically
increased the total treatment time, which is due not only to the extra modulation of the beam but also
to the increase in number of beams used. Lower treatment times keep movement of the PTV to a
minimum when considering intrafraction motion. This will most likely lead to a better outcome even in
the cases where the PTV margins have already been reduced. This reduction in total time will also allow
busy departments to treat more patients on one machine in one day because each patient will fit into a
smaller time slot.
The monitor units have been shown to be lower for the VMAT plans except for the case of the
study by Quan et al, which showed that the VMAT plans had slightly higher monitor units.
9
The benefit
of lowering monitor units is a reduction in scatter and leakage radiation exposure to the patient. This
will reduce the likelihood of the patient developing secondary malignancies, which is especially
important in younger patients who are expected to live longer. Secondary malignancies have been
known to appear up to 20 years after the initial exposure.
12
13


Conclusion
Volumetric-modulated arc therapy is a viable option and may become the gold standard for
prostate cancer in the future. Because it is a new technology, more time is needed to fully understand
the implications and results of this type of treatment. As far as the preliminary results are concerned,
VMAT plans do an excellent job at all of the areas that were investigated.
The target coverage by the VMAT plans is comparable to the IMRT plans and can easily achieve
the goals set by the radiation oncologist. They are also excellent at keeping the doses to the OARs at
levels comparable to IMRT, which is better for the patient when considering both early and late effects
of radiation exposure. The total treatment time with VMAT is dramatically reduced which is of great
benefit to the patient as well as the clinic. Also, reducing the exposure to the patient by scatter and
leakage radiation can only help in reducing the likelihood of secondary cancers.









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Table 1. Target Coverage
Target Coverage
Study 3-D IMRT VMAT
Wolff et al
3
(Rx 76
Gy)
99% of the target
covered by an average
of 71.020.58
the dose to 99% of
the PTV was 66.461.9
Gy
average dose to 95%
of the target was
71.59 Gy
Palma et al
2
(Rx 74
Gy)
conformality index (i.e.
the volume of
95%/PTV) was 1.36
conformality index (i.e.
the volume of
95%/PTV) was 1.12
conformality index (i.e.
the volume of
95%/PTV) was 1.12
Sale et al
4
(Rx 75.6
Gy)
95% of the PTV
covered by a mean of
75.88 Gy
the mean dose to 95%
of the PTV was 76.10
95% of the PTV
received 75.89
Kopp et al
7
(Rx 77.4
Gy)
n/a
an average of 99.33%
of the PTV covered by
the total dose
an average of 98.26%
of PTV covered by
total dose
Afghan et al
8
n/a
the volume of the PTV
covered by 95% of the
prescribed dose was
96.7%.
the volume covered by
95% of the target dose
was 98.9%.

Table 2. Dose to Organs at Risk
Dose to Organs at Risk
Study 3-D IMRT VMAT
Wolff et al
3
(Rx 76
Gy)
mean dose to the
posterior rectum is
55.43 Gy
the mean dose to the
posterior rectum is
34.891.81 Gy
the mean dose to the
posterior rectum is
38.571.81 Gy
Palma et al
2
(Rx 74
Gy)
rectum V40 is 66.8% rectum V40 is 17.1% rectum V40 is 15.9%
Sale et al
4
(Rx 75.6
Gy)
rectum V40 is 66.01% rectum V40 is 48.89% rectum V75 is 12.04%
Kopp et al
7
n/a
25% of the rectum
received 40 Gy
25% of the rectum
received 57.10 Gy
Afghan et al
8
n/a
mean dose to rectum
is 79.5
mean dose to the
rectum is 80.8 Gy


15

Table 3. Monitor Units
Monitor Units
Study 3-D IMRT VMAT
Wolff et al
3
(Rx 76
Gy)
the average total
monitor units were
2528
the average total
monitor units were
544
total monitor units
were an average of
386
Palma et al
2
(Rx 74
Gy)
mean total monitor
units were295.5
mean total monitor
units were 788.8
mean total monitor
units were 454.2
Tsai et al
9
n/a mean of 336.116.8 mean of 309.7
Afghan et al
8
n/a
average monitor units
were 621
average monitor units
were 536
Kry et al
6
the mean was 233 and
the max was 254
the mean was 986
and the max was 1211
n/a

16

References:
1. Siegel R, Ward E, Brawley O, Jemal A. Cancer Statistics, 2011. The impact of eliminating
socioeconomic and racial disparities on premature cancer deaths. Amer Cancer Soc. 2011;212-
236. doi:10.3322/caac.20121.
2. Palma D, Verbakel W, Otto K, Senan S. New developments in arc radiation therapy: A review.
Cancer Treatment Reviews.2010.393-399. doi:10.1016/j.ctrv.2010.01.004
3. Wolff D, Stieler F, Welzel G, Lorenz F, Abo-Madyan Y, Mai S et al. Volumetric modulated arc
therapy (VMAT) vs. serial tomotherapy, step-and-shoot IMRT and 3D-conformal RT for
treatment of prostate cancer. Radiotherapy and Oncology. 2009;(93):226-233.
doi:10.1016/j.radonc.2009.08.011
4. Sale C, Moloney P. Dose comparisons for conformal, IMRT and VMAT prostate plans. J Med
Imaging Radiation Oncology. 2011;(55):611-621. doi:10.111/j.1754-9485.2011.02310.x
5. Palma d, Vollans E, James K, Nakano S, Moiseenko V, Shaffer R et al. Volumetric modulated arc
therapy for delivery of prostate radiotherapy: comparison with intensity-modulated
radiotherapy and three-dimensional conformal radiotherapy. Int J Radiation Oncology Biol Phys.
2008;(72):996-1001.
6. Kry S, Salehpour M, Followill D, Stovall M et al. The calculated risk of fatal secondary
malignancies from intensity-modulated radiation therapy. Int J Radiation Biol Phys.
2005;(62):1195-1203. doi:10.1016/j.ijrobp.2005.03.053
7. Kopp R, Duff M, Catalfamo F, Shah D, Rajecki M, Ahmad K. VMAT vs. 7-field IMRT: Assessing the
dosimetric parameters of prostate cancer treatment with a 292-patient sample. Med Dosimetry.
2011;(36):365-372.
8. Afghan M.K.N, Cao D, Mehta V, Wong T et al. Volumetric Modulated Arc Therapy for Prostate
Cancer. Int J Radiation Oncology Biol Phys. 2008;(72):3103.
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9. Tsai C, Wu J, Chao H, Tsai Y, Cheng J. Treatment and dosimetric advantages between VMAT,
IMRT, and helical tomotherapy in prostate cancer. Med Dosimetry.2010;(36):264-271.
10. Quan E, Li X, Li Y, Wang X, Kudchadker R, Johnson J et al. A comprehensive comparison of IMRT
and VMAT plan quality for prostate cancer treatment. Int J Radiation Oncology Biol
Phy.2010;(83):1169-1178. doi:10.1016/j.ijrobp.2011.09.015
11. Yu C. Intensity-modulated arc therapy with dynamic multileaf collimation: an alternative to
tomotherapy. Phy Med Biol.1995;(40):1435-1449.
12. Ruben J, Davis S, Evans C, Jones P et al. The effect of intensity-modulated radiotherapy on
radiation-induced second malignancies. Int J Radiation Oncology Biol Phys.2008;(70);1530-1536.
doi:10.1016/j.ijrobp.2007.08.046

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