Katrina Lee

Clinical Practicum III

Hybrid Irradiation for Esophageal Cancer
Hybrid radiation therapy is a combination of treatment modalities within one plan.
Hybrid therapy is utilized for any type of treatment where a conventional approach is not
adequate. Some examples of hybrid therapy include mixed beam energies such as combination
photon and electron beams and dual energy treatment plans. The use of more sophisticated
treatments such as intensity-modulated radiation therapy (IMRT) and volume-modulated arc
therapy (VMAT) are being combined with conventional treatments to provide the best possible
outcomes for patients. The hybrid technique utilized and discussed in this document combines
conventional external beam radiation therapy with VMAT. This technique has proven to be
beneficial when treating cancers encompassed by vital organs. The esophagus is one such
example, because it is surrounded by critical dose limiting structures such as the heart, lungs, and
spinal cord. Utilizing a hybrid treatment planning approach to treat esophageal cancers has the
advantage of covering the target volume with the prescription dose while simultaneously
reducing the amount of low dose to the lungs.1
The patient discussed in this paper is a 60 year old male who presented with stage III mid
to upper esophageal cancer in August 2014. His diagnosis was confirmed by biopsy tissue taken
while undergoing an upper gastrointestinal endoscopy. The biopsy samples confirmed poorly
differentiated adenocarcinoma of the esophagus. The patient was referred to a radiation
oncologist after meeting with a medical oncologist regarding chemotherapy. Both physicians
collaborated and decided that a concomitant regimen of chemotherapy and radiation would
provide the best outcome for the patient.
A General Electric CT scanner was used to acquire images of the patient for treatment
planning. The patient was scanned in a supine position on the CT simulation couch with the arms
extended above the head, elbows resting on a wing board, with a head rest for patient comfort. A
VacLoc was formed to immobilize the patient and improve reproducibility. A cushion was
placed under the knees to reduce pressure on the low back, and permanent marks were placed on
the patient for daily set up.
The treatment planning CT was sent to the Eclipse 11.0 treatment planning system. The
organs at risk (OR) contoured included the heart, spinal cord, bilateral lungs, and the liver. A
PET CT was performed on the patient during the diagnostic screening process which was then
fused to the treatment planning CT for enhanced target delineation. The physician utilized the
1

Katrina Lee
Clinical Practicum III
fused PET CT to draw the gross tumor volume (GTV). The GTV was then expanded to create
the planning tumor volume (PTV). The physician prescribed a dose of 4500 cGy delivered at a
rate of 180 cGy per fraction to the PTV over a course of 25 fractions.
The initial treatment plan consisted of two 10 MV fields, anterior (AP) and posterior
(PA). It was calculated so the PTV would receive half of the prescription dose, or 2250 cGy (90
cGy in 25 fractions). A 0.4 cm margin was placed around the PTV using the multileaf collimator
(MLC) for blocking. The MLC margin can be viewed in Figure 1. After the plan was calculated,
the field weight was adjusted to reduce dose to the normal tissues in the anterior and posterior
regions. The maximum dose was reduced to 115% (2587.5 cGy) of the planned prescription dose
(2250 cGy). This plan was then used as the base plan for the VMAT portion of the hybrid
treatment plan.
Along with contoured OR, more structures were contoured specifically for use in the
VMAT optimizer. An optimization ring, shown in Figure 2, was created by expanding the PTV
by 3 cm. It was then cropped 2 cm from the PTV, the result being a 1 cm ring, 2 cm from the
target volume. There was another structure created and used for optimization named Heart
Avoid. The OR Heart was cropped from the PTV by 0.4 cm. The heart avoidance structure can
be viewed in Figure 3.
The volume of the PTV contoured within the lungs could pose a problem with obtaining
coverage of the prescription dose due to the photon interaction in air. Therefore, two PTV
structures were generated to manipulate the dose within the optimization algorithm. The portion
of the PTV within solid tissue was cropped from the lungs and named PTV Tissue. The second
PTV structure for VMAT optimization was labeled PTV Lung. This structure added a 0.1 cm
expansion on the PTV and was cropped 0.2 cm from PTV Tissue. The expansion of the PTV
Lung helped to manipulate the optimizer into placing dose around that structure. Figure 4 depicts
the structures for VMAT optimization.
After the optimization structures were created, arc fields were added and adjusted. Two
large arc fields, 200-160 clockwise (CW) and 160-200 counter clockwise (CCW), were used
for the treatment plan with a 350 and 10 collimator rotation, respectively. The jaws were
adjusted as need for VMAT by observing rotation around the PTV. The field sizes used for
VMAT optimization were 15x22.3 cm and 15x22.8 cm for the CW and CCW fields,

Katrina Lee
Clinical Practicum III
respectively. The two arc fields and their respective collimator rotations can be viewed in Figure
5.
The VMAT was planned to the entire prescription dose, 4500 cGy. The AP/PA plan was
inserted into the optimizer as a base dose plan and normal tissue objectives were selected. Upper
and lower dose constraints were placed on the two PTV structures. The PTV Tissue was assigned
a lower constraint of 4500 cGy, and an upper constraint of 4580 cGy. The PTV Lung, however,
was given higher dose constraints to meet, 4600 cGy and 4650 cGy. Upper constraints were
given to the total lungs to reduce the low dose that the OR would receive during treatment, and
the heart avoid structure was pushed to reduce dose to the heart. The spinal cord dose was
scrutinized throughout optimization, never close to reaching tolerance.
After the initial optimization was complete, a plan sum was generated to review the entire
hybrid treatment plan. Upon evaluation, the most inferior aspect of the PTV was not adequately
covered with the prescription dose. A new structure was then produced to enable the optimizer to
cover the PTV with at least 95% of the prescribed dose. The plan sum's 95% isodose line (4275
cGy) was converted into a structure and named Dose 95%. The overlap between Dose 95% and
the PTV, shown in Figure 6, was developed using the Boolean operators tool. The newly created
Dose 95% accounted for the areas within the PTV receiving the prescribed dose. Another
structure was needed to push dose into regions not receiving the required dose coverage. This
structure was created and named Push 4275. The PTV was cropped from Dose 95% to make this
structure. Figure 7 shows Push 4275 in relation to the PTV. Once again the plan was optimized
with a lower dose constraint on Push 4275 of 4580 cGy and given a high priority. The optimizer
adjusted the dose distribution and the plan sum was analyzed once the calculation was complete.
The hybrid treatment plan provided coverage of the target volume and reduced the
amount of low dose to the lungs. Analysis of the hybrid treatment plan showed 95% of the
prescribed dose covered 100% of the PTV. The 50%, 95%, 98%, and 100% isodose lines can be
viewed in the axial, sagittal, and transverse planes in Figures 8, 9, 10, and 11, respectively.
The DVH was used to analyze the ORs from the plan sum were according to RTOG
(Radiation Therapy Oncology Group) dose constraints. Structures considered significant for
evaluation were the bilateral lungs, heart, and spinal cord. The constraint for the volume of lung
tissue receiving 20 Gy must be less than 30% of the total volume (V20 < 30%). The V20 for the

Katrina Lee
Clinical Practicum III
plan was well below the goal being only 17.6%. The doses the spinal cord and heart received
were also within tolerance. The DVH for the plan can be viewed in Figure 12.
The hybrid treatment plans combined to produce a homogenous dose distribution
throughout the target volume. It had the added benefit of reducing the overall dose to the
bilateral lungs. This hybrid modality, though effective has some critical issues to consider. As is
true in all treatment planning, the physician must weigh the risks versus benefits of the dose
distribution to OR. There has been evidence that this type of hybrid treatment planning increases
the heart dose while reducing low dose in the lungs.1,2
This project provided me a deeper understanding of treatment planning and more
experience with VMAT. Overall, a tremendous amount of knowledge was gained throughout this
project. In retrospect, if I did this plan over again I would approach it bit differently. I would
place a higher priority on the V5 and V10 of the lung to further reduce the amount of low dose.
Initially, I began this project timidly, but now feel much more confident about producing quality
hybrid treatment plans.

Katrina Lee
Clinical Practicum III
References
1. Mayo CS, Urie MM, Fitzgerald TJ, Ding L, Lo YC, Bogdanov M. Hybrid IMRT for
treatment of cancers of the lung and esophagus. Int J Radiat Oncol Biol
Phys. 2008;71(5):14081418. http://dx.doi.org/10.1016/j.ijrobp.2007.12.008
2. Vosmik M, Petera J, Sirak I, et al. Technological advances in radiotherapy for esophageal
cancer. WJG. 2010;16(44):5555-5564. http://dx.doi.org/ 10.3748/wjg.v16.i44.5555

Katrina Lee
Clinical Practicum III
Figures

Figure 1: DRRs from the anterior and posterior beams, respectively.

Figure 2: The 1 cm avoidance ring (shown in pink) created for optimization and is 2 cm from the
PTV (shown in blue)

Katrina Lee
Clinical Practicum III

Figure 3: The heart optimization structure (shown in red) cropped 0.4 cm from the PTV (shown
in blue)

Figure 4: PTV Lung (shown in purple) grown 0.1 cm from the PTV (shown in blue) and cropped
0.2 cm from the PTV Tissue (shown in red-violet)
7

Katrina Lee
Clinical Practicum III

Figure 5: The two fields used for VMAT optimization depicting their respective collimator
rotation

Figure 6: Structure created from the 95% isodose line (shown in pink) within the PTV

Katrina Lee
Clinical Practicum III

Figure 7: Optimization structure Push 4275 (shown in red) to push dose into the PTV

Figure 8: Shows the hybrid plan sum at the 50% isodose line

Katrina Lee
Clinical Practicum III

Figure 9: Shows the hybrid plan sum at the 95% isodose line

Figure 10: Shows the hybrid plan sum at the 98% isodose line

Figure 11: Shows the hybrid plan sum at the 100% isodose line

10

Katrina Lee
Clinical Practicum III

Figure 12: Hybrid plan DVH

11