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Ashley Walsh
Clinical case study #1
February 6, 2015
Volumetric Modulated Arc Therapy (VMAT) for Esophageal Cancer
History of Present Illness: Patient DD is a 68 year-old male who first noted some early signs of
dysphagia around August of 2014. Eating dinner prompted significant dysphagia and vomiting
along with nausea. A GI workup was done which included endoscopy with biopsy followed by
PET/CT. The PET showed a 3cm lesion at the distal esophagus. There were no positive lymph
nodes or distant metastatic disease. The final staging diagnosed poorly differentiated
adenocarcinoma of the distal esophagus and is a clinical stage IB (T3, N0, M0) status post
biopsy. DD has a medical history of gastroesophageal reflux disease and according to the NCI
based on fair evidence, an association exists between GERD and adenocarcinoma, particularly if
the GERD is long-standing and symptoms are severe.1
In early January 2015, the patient was referred to the radiation oncology department for a
consultation for radiation to the esophagus. The radiation oncologist reviewed the patients
records and discussed various treatment regimens with DD. The physicians recommended
neoadjuvant chemotherapy to 50.4Gy in 28 fractions via an Intensity modulated radiotherapy
(IMRT) technique along with daily image guidance. The radiation oncologist then discussed the
benefits and side effect complications of esophageal irradiation with the patient. DD elected to
proceed with neoadjuvant chemotherapy radiotherapy.
Past Medical History: DD has a past medical history of acid reflux disease, benign prostatic
hypertrophy, diabetes, high cholesterol, hypertension, kidney stones, lower urinary tract
symptoms and prostate cancer.
Social History: DD worked until 65 years-old as a factory worker in a neighboring city. DD is
married with three adult children. The patient is a 30 year one pack a day smoker, who quit
smoking 3 years ago. DD states that he consumes 3 drinks per-week and denies any drug use.
The patient reported that his mother and grandmother died from ovarian cancer and his father
died of a myocardial infarction.
Medications: DD uses the following medications: Lorazepam, Amlodipine Besylate, Avodart,
Pantoprazole, Pravastatin, Ropinirole, Terazosin.

Diagnostic Imaging: In mid-December 2014, DD was seen for restaging of esophageal cancer
by having a PET/CT done. The findings were hypermetabolic activity with associated thickening
in the distal esophageal carcinoma. The maximum length was 3.3 cm. The patient was then
clinically staged as IB (T3, N0, M0).
Radiation Oncologist Recommendations: The standard options for treatment are currently,
surgery alone or chemotherapy and radiation. The use of all three modalities is currently under
clinical evaluation2. After review of DDs clinical staging and PET/CT the radiation oncologist
recommended DD to undergo neoadjuvant chemotherapy radiotherapy to 50.40Gy in 28
fractions via IMRT technique along with daily image guidance to help enhance the dose to the
tumor while minimizing dose to the surrounding lung, spinal cord, heart and bowel for this distal
esophageal lesion. The risks, benefits, and possible side effects were explained to the patient and
he expressed understanding and is agreeable with the plan.
The Plan (prescription): The radiation oncologists treatment recommendation to DD was an
IMRT plan in which nonuniform fluence is delivered to the patient from any given position of
the treatment beam to optimize the composite dose distribution.2 The prescription was 50.4Gy to
be delivered at 1.8Gy per fraction for 28 fractions. With an the initial volume going to 45Gy and
then a cone down to include the primary site of the disease to receive an additional 5.4Gy for a
total of 50.4Gy.
Patient Setup/Immobilization: In mid-January 2015, DD underwent a CT simulation scan for
radiation therapy treatment. The patient was placed in the supine position on the CT simulation
couch with both arms raised and positioned above his head on a wing board immobilization
device (Figure 1). The patient had a custom vaclock bag on top of the wing board with a head
rest underneath the vaclock bag for comfort (Figure 2). The patient had a wedge sponge under
his knees for support. The radiation oncologist marked the patient in the center of his chest and
on each side. Next the therapist added an additional set of marks for leveling purposes on the
machine each day.
Anatomical Contouring: After completion of the CT simulation scan, the CT data set was
transferred to our MIM workstation. Here the PET/CT was deformed and fused to the
treatment planning CT data set so the tumor could be contoured by the physician. The medical
dosimetrist contoured organs at risk (OR) which included the right and left lungs, a total lung
volume, the heart, carina, stomach, normal tissue, right and left kidney and liver. The radiation

oncologist reviewed each OR, and approved them so treatment planning could begin. The
medical dosimetrist was given the simulation note which includes the prescription and
expansions to create the planning target volume (PTV). The CT data set with the contours was
then transferred to the Pinnacle3 version 9.8 treatment planning system (TPS).
Beam Isocenter / Arrangement: The medical dosimetrist first did the expansion for the initial
treatment of 45Gy from the clinical target volume (CTV) to the PTV which was 1.0 cm. The
isocenter was auto-placed using the centroid technique in the middle of the PTV volume, which
fell anterior to thoracic vertebrae number eight (T8) (Figures 3-6). The dosimetrist decided the
degree of rotation on the first beam and then let Pinnacle copy the parameters to enact the second
beam. The collimator was rotated 15 degrees and the arc degree was set to start at 205 and stop at
150. The computer generated second beam started at 150 and stopped at 205 (Figure 7). A full
360 degrees was not chosen for this patient to help spare the cord dose from a geographic miss
The tumor was fairly centrally located and even shaped to where coverage would not be a hurdle.
For the boost, a 1.0 cm expansion was added to the gross tumor volume (GTV) to create the
boost PTV volume. The dosimetrist then added a single arc beam starting at 225 and stopping at
140 degrees. A single arc was utilized for the boost as it was a smaller volume and that would
decrease the amount of time the patient was on the table.
Treatment planning: The radiation oncologist outlined the dose prescription and objectives for
the IMRT plan. The objective was to use a combination of an initial larger volume and a smaller
boost volume to treat the area of disease to 50.4Gy while maintaining an adequate and
homogenous dose distribution throughout the tumor volume (Figures 8-14). The prescription
dose for the treatment was prescribed to the dosimetrist placed isocenter. The objectives for the
tumor volume that were entered into the IMRT module of the TPS were a maximum, minimum
dose corresponding with the prescribed dose and minimum DVH of prescription dose to 95% of
the volume. In addition, the OR dose constraints of the IMRT portion were: the stomach
maximum dose volume histogram (DVH) had two objectives, the first was 13% of the stomach
was to stay < 36Gy and 38% of the stomach was to stay < 23Gy. The cord was expanded 2 mm
for planning purposes and was set as a max dose of 35Gy. And lastly a ring was used to keep the
dose to uninvolved tissues to < 85% of prescription dose. The ring was designed to have a 3mm
space between the PTV and the ring edge and was a 1cm ring. The TPS utilized the direct
machine parameter optimization (DMPO) feature with 75 segments to accomplish the objectives

and parameters. Once adequate prescription dose coverage was achieved to the PTV volume the
medical dosimetrist reviewed the OR doses, the isodose lines, and the DVH. The OR on the
DVH (Figure 15) reflected a maximum heart dose of 54Gy, the cord maximum dose was 22Gy,
and the right and left kidneys both had a mean dose less than 7Gy. The plan was assigned a
normalization of 95% by the dosimetrist to ensure 95% coverage of the PTV by the prescription
isodose line.
Quality Assurance/Physics Check: We cannot perform a monitor unit check using the RadCalc
program with VMAT treatments. A medical physicist performed a check of the beams using
mapcheck. The complete IMRT treatment plan was reviewed by a medical physicist for a final
check before treatment began.
Conclusion: The VMAT planning technique presented the medical dosimetrist with several
challenges. One challenge was maintaining a daily reproducible setup of the patient. The
patients daily setup reproducibility and respiratory motion presented obstacles for accurate
delivery of the ARC IMRT plan. The biggest difficulty the medical dosimetrist encountered with
this plan was maintaining coverage and keeping all the critical structures in the field below their
dose tolerances. Since the center is relatively new at using VMAT, the dosimetrist initially
planned the case using static beams before trying VMAT. Next time the dosimetrist will start
with VMAT and not waste the time planning an IMRT treatment that will not be used.

Figure 1. Patient position from CT simulation

Figure 2. Patient position from CT simulation with a wing board and vac-lock bag

Figure 3. Isocenter placement

Figure 4. Isocenter placement in the axial view

Figure 5. Isocenter placement in the sagittal view.

Figure 6. Isocenter placement in the coronal view.

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Figure 7. IMRT field sizes automatically determined by the TPS and ARC rotation.

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Figure 8. VMAT IMRT dose distribution of the esophagus

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Figure 9. VMAT IMRT dose distribution of the esophagus

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Figure 10. VMAT IMRT dose distribution of the esophagus

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Figure 11. VMAT IMRT dose distribution of the esophagus

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Figure 12. VMAT IMRT dose distribution of the esophagus.

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Figure 13. VMAT IMRT dose distribution of the esophagus.

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Figure 14. VMAT IMRT dose distribution of the esophagus.

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References
1. National Cancer Institute. Esophagus Cancer. National Cancer Institute Website.
http://www.cancer.gov/cancertopics/type/esophagus. Accessed February 15, 2015.
2. Faiz M. Khan, The Physics of Radiation Therapy. 4th ed. Baltimore, MD: Lippincott
William & Wilkins; 2010:431.