1

Does an Ideal Collimator Pair Exist for 2-Arc VMAT Prostate Plans?

Charity Rogstad, R.T.(R)(T), Paul Tabeek R.T.(T), Michael May, R.T.(R)(T), Jessica Ezelle,
R.T.(T), Ashley Hunzeker MS., C.M.D., Nishelle Lenards, R.T.(R)(T), MS. C.M.D.

ABSTRACT

Introduction

The most common malignancy found in men and one of the major causes of cancer death
is prostate cancer. This disease effects 233,000 men annually and is the cause of 1-2% deaths
among men.1,2 This disease carries greater predominance in the western world and among the
migrant population, suggesting that there are lifestyle and environmental risk factors that
contribute to the development of prostate cancer. In the United States, prostate cancer is the
second most common cancer-related cause of death among men.1
The treatment of prostate cancer with radiation therapy has greatly evolved through the
years. In recent past, it was the common standard to treat prostate cancer in men with static
intensity modulated radiation therapy (IMRT), which achieved great outcomes leading to fewer
cancer deaths. The evolution of static IMRT, with the emergence of new technology, has led to a
new method of delivering radiation therapy to prostate cancer patients called volumetric
modulated arc therapy (VMAT). Unlike static IMRT, where the gantry moves itself into position,
delivers modulated radiation, turns off and proceeds to the next beam angle, VMAT can treat the
entire prostate in one 360 arc without stopping. With this ability to treat the equivalent of 5 to 9
static beams in 1 to 2-arc beams there is a reduction in treatment time, allowing for better patient
comfort and a lower probability of intrafractionation movement.3 Volumetric modulated arc
therapy plans are produced by modulating the speed of the gantry, dose rate, and the multi-leaf
collimator (MLC) positions simultaneously to create a homogenous dose distribution to the
planning target volume (PTV). This allows for a sharper dose gradient between the PTV and the
surrounding critical structures that are to be avoided.4 Volumetric modulated arc therapy also
allows for a reduction in the number of monitor units (MUs) used in the treatment planning
process, reducing the likelihood of the patient developing a secondary malignancy as a result of
their radiation treatments.2,5
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Volumetric modulated arc therapy for prostate cancer provides benefits that arguably
outweigh traditional static IMRT plans with similar PTV coverage and lower overall doses to the
organs at risk (OR). However, the benefits of a VMAT plan may be capable of showing even
more superiority to traditional static IMRT plans with the theory that there is an ideal set of
collimator angles to be used in conjunction with a 2 arc VMAT prostate plan. A study performed
by Tas et al6, concluded that there was an ideal set of collimator angles when planning VMAT
treatments. However, only a few collimator pairs were tested and the study concluded with
limited data.
Anderson et al7 took this idea and performed their own study that showed evidence of
prostate plans with collimator pairs of 15 and 30 were superior. This lead to a conclusion that
collimator pairs of 15 and 345 and 30 and 330 for 2 arc VMAT plans were considered to be
ideal collimator pairs. Using this data that 30 collimator angles are superior in the delivery of
VMAT prostate plans, the purpose of this study was to determine if there is a better matching
pair for the collimation of the second arc. Each plan contained 2 VMAT arcs, the first arc with a
collimator angle of 30 and the second arc adjusted 6 times to, 345, 330, 315, 300, 285,
and 270. Each plan was compared against the other and against the reference plan, with the
suggested ideal collimator angles of 30 and 330, according to Anderson et al7.

Methods and Materials

Patients
The patients selected for this study included 10 men in need of prostate and seminal
vesicle radiation treatment. Five of these patients were planned in the Eclipse Treatment
Planning System (TPS) and the other 5 were planned in the Pinnacle TPS. All patients underwent
a simulation process prior to treatment. This consisted of the patient being set-up in the treatment
position, supine with a foam double knee immobilization cushion indexed to the simulation
table, their hands holding a foam hand ring across their chest and an F headrest indexed to the
table underneath their head for support. Reference marks were placed on the patients pelvis
using radiopaque markers to establish an isocenter and a CT was obtained of the patient in this
position using 3 mm slice thickness. The patient received permanent tattoos in the place of the
radiopaque markers to ensure the marks were kept until treatment and the CT scan was sent to
the respective TPS.
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Contouring

Each patient was brought into the respective TPS, and the isocenter was marked
accordingly per the radiopaque markers placed in simulation. Contouring of the prostate and the
seminal vesicles along with the OR, which included the bladder, rectum and femoral heads,
began so that they could be used for segmentation and planning. The gross tumor volume (GTV)
for these plans consisted of the prostate and the seminal vesicles. A 5 mm margin was added to
the GTV to create a PTV, as the target structure of the treatment plan.

Treatment Planning
There were two treatment planning systems used in this study, Eclipse and Pinnacle, each
containing 5 patients. A consistent 3.0 cubic-millimeter dose grid resolution was kept standard
among all treatment plans. Two VMAT arcs with opposing directions (clock-wise and counter-
clockwise) were used at the treatment beams with a path length of 356 (178 to 182) each and
a gantry control spacing of 4 was applied. The clock-wise arc, collimator angle was set at the
consistent 30 for the purpose of achieving an optimal plan to compare all collimator angles
against. The counter-clockwise arc, collimator angle was set to the perceived ideal collimator
pair of 330.
There was a standard treatment prescription of 79.2 Gy in 44 fractions with an acceptable
PTV coverage of 95% PTV volume covered by the prescription dose. To create the optimal plan
for each individual patient, proper priority weightings were paired with the same set of
optimization parameters at the start of planning as seen in Table 1. Once the initial, reference
plan was created and met the set criteria of the study as seen in Figure 3, the plan was then
copied into a new trial and the counter-clockwise collimator angle was changed, while the
clockwise collimator angle remained the consistent 30. The initial plan contained the paired
collimator angles considered optimal by Andersen et al7 of 30 and 330. The constraints and
priorities found optimal in the initial reference plan remained the same and each additional
collimator angle of 345, 315, 300, 285, and 270 for the counter-clockwise arc were
recalculated with these goals to mimic the same optimization.

Plan Comparison
After all the plans were generated, their dose volume histograms (DVH) were used to
collect various data from each of the plans. The values configured that were most important to
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this study included conformity index (CI), the homogeneity index (HI), the intermediate dose
spillage, and the gamma analysis. Each of these values played a role in calculating the quality of
the prescription coverage of the PTV. Additionally the OR doses were compared to see if there
was any significant reduction of dose to the organs.
The International Commission on Radiation Units (ICRU) establishes CI as the volume
of the reference isodose divided by the target volume.8 To achieve an optimal CI, the shape of
the high dose isodose curves should conform to the exact shape of the PTV. Conformity index
ranges on a scale of 0 to 1, with a CI of 1 being the optimal goal. A CI less than 1 indicates that
the entire PTV is not receiving 100% of the prescription dose. Conformity indices greater than 1
illustrates that the PTV is exceeding the prescribed coverage and the dose is now invading the
surrounding healthy tissue. Achieving an optimal CI of 1 is one of the fundamental goals during
the treatment planning process. However, most radiation oncologists follow the common
standard prescription requirement that 95% of the PTV volume to be covered by the prescription
dose.8
These plans were also compared in terms of HI. Homogeneity index is an objective tool
used to analyze the dose distribution within the PTV.9 Gong et al10 defined HI as the minimum
dose in 5% of the PTV divided by the minimum dose in the 95% of the PTV (D5/D95). The closer
the HI index gets to its lowest value of 1, the more homogeneous the dose distribution is
throughout the PTV.9
Intermediate dose spillage is another analyzing value used to compare the conformality of
the PTV among the plans. Using the ratio of the 50% isodose volume (R50%) divided by the
PTV volume (R50%/VPTV), the intermediate dose spillage was calculated for each plan. The lower
the value of R50%/VPTV, the more homogeneous the dose with steeper dose fall-off and increased
dose conformality of the PTV dose.11
Lastly, gamma analysis was used to test the patient specific quality control (QC) of the
VMAT treatments as recommended by the Institutional guidelines for IMRT QC recommend.
This analysis may be obtained by way of numerous measurement devices available to radiation
oncology institutions, including ionization chambers and diode array detectors. In this study,
Mobius3D was used to perform the patient specific QC. Gamma analysis allows for an accurate
assessment of patient specific treatment volumes by evaluating the dose distribution point by
point in comparison to the dose distribution created in the TPS using a distance to agreement
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(DTA) measurement and dose difference (DD) measurement. Each point was calculated and if it
passed the set criteria, it is given a gamma value of <1 and each of the passing points are
calculated to determine whether the plan passes or not, depending on the institutions passing
criteria.12 Gamma analysis is important to this study because collimator angles can impact the
deliverability of a VMAT plan due to gravitys impact on the MLC. A plan may have optimal
CI, HI and intermediate dose spillage values, but if gravity affects the motion of the MLC during
treatment, the plan may not be delivered to the patient as planned in the TPS.13
Using the values CI, HI, intermediate dose spillage, and gamma analysis value, each
factor was averaged per collimator angle among all the patients and the 330 collimator was used
as our reference angle since it was predetermined by Andersen at al7 to be an optimal collimator
angle to be paired with the studys constant collimator angle of 30. Using the CI, HI,
intermediate dose spillage and gamma analysis value averages, p-values and t-values were
calculated to help determine the significance of the results. P-values calculate the probability, in
statistical terms, that the observed result is true of the null hypothesis allowing for the
determination of how significant the results are to the study. The t-value yields evidence of
meaningful variances between the calculated value and the control value, the 330 collimator
angle.14 Each of the averaged CI, HI, intermediate dose spillage, and gamma analysis values was
entered into an online software, GraphPad, using their QuickCalcs calculator to obtain the p-
value and t-values for each result.15

Results
After comparing each of the plans, there was a conclusion that there was no statistically
significant data that suggested that any of the collimator angles tested were considered an ideal
pair to the 30 collimator angle for a 2 arc VMAT prostate plan. None of the tested collimator
angles, including the suggested 330 angle by Andersen et al7, had consistent PTV coverage
quality among all of the test analyzing values. First the maximum and mean doses for the OR
were averaged and compared to see if there was any significant dose reduction to the rectum,
bladder or femurs for any of the collimator angles as seen in Table 2. Then, the most superior CI,
HI, intermediate dose spillage and gamma analysis values for each patient were identified. This
method proved inconclusive of a collimator angle with superior dose coverage quality of the
PTV. Next, all of the analysis values were averaged together according to collimator angle and
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once again compared for consistency amidst one common collimator angle. Once again, this
method proved inconclusive of a collimator with superior dose coverage quality of the PTV.
When there was not a statically significant collimator angle proven to better the treatment
results of VMAT treatment plans of the prostate, p-values and t-values were calculated for each
of the averaged CI, HI, intermediate dose spillage and gamma analysis values of each collimator
angle being compared to the 330 angle as found in Table 3 and Figures 1 and 2. Almost all of
these values came back statistically insignificant with the exception of the p-value and t-value of
the gamma analysis value of the 315 collimator angle and the p-value and t-value of the
intermediate dose spillage of the 270 collimator angle. Nonetheless, even with the p-value and t-
value of the gamma analysis of the 315 collimator angle and the intermediate dose spillage of
the 270 collimator angle being statistically significant, the data was still inconclusive as to a
collimator angle that could consistently demonstrate across all tested values its superiority in
quality of PTV dose coverage.

Discussion
This study was unsuccessful in detecting a specified pair of collimator angles that would
advance VMAT planning of the prostate. Within this study, it was concluded through several
PTV dose coverage quality analyzation values, that the preceding study stating that the
collimator angle pair of 30 and 330 is an optimal choice for a 2-arc VMAT prostate plan, was
not statistically consistent in its quality of dose coverage to the PTV throughout all 10 cases
derived in this study. It is possible that Andersen et al7 may have happened upon a more optimal
set of dose constraints within their optimizer when calculating their beams, which lead to their
findings of their ideal paired collimator angles. Furthermore, it was discovered that none of the
beams selected for this study were contenders to be an ideal collimator pair for a 2-arc VMAT
prostate plan when paired with a collimator angle of 30. None of the results concluded in this
study were statically advantageous in any way.
Conclusion
It is possible that there is not an ideal paired collimator angles for 2-arc VMAT
prostate plans. If it were possible then it should have been achievable to obtain consistently
optimal analyzed conformality values of the PTV at least for the paired collimator angles of 30
and 330, as per Andersen et al.7 Optimal conformality of the PTV may all be attributed to how
well the medical dosimetrist optimizes his or her dose constraints when calculating their beams
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and might not have anything to do with the angles he or she chooses for their collimators. Having
a larger patient population and the ability to produce a larger amount of data may have led to the
possibility of finding a consistent collimator pair among the chosen angles. In future studies,
these collimator angles may be tests with a new set of optimization parameters in hopes that the
30 and 330 collimator pair plan would at least have the same ideal parameters as found in
Andersen et al7. With these new optimization parameters hopefully one of the other 5 collimator
angles chosen to pair with the 30 collimator angle will show superiority in conformality of the
PTV.
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References

1. Attard G, Parker C, Eeles R, Schroder F, Tomlins S, Tannock I, Drake C. Prostate

Cancer. The Lancet. 2016;387(10013):70-82. https://doi.org/10.1016/S0140-
6736(14)61947-4.
2. Eggener SE, Cifu AS, Nabhan C. Prostate cancer screening. JAMA. 2015;314(8):825-
826. http://dx.doi.org/10.1001/jama.2015.8033.
3. Sze H, Lee M, Hung WM, Yau TK, Lee A. RapidArc radiotherapy planning for
prostate cancer: single-arc and double-arc techniques vs. intensity-modulated
radiotherapy. Med Dosim. 2012;37:87-91.
http://dx.doi.org/10.1016/j.meddos.2011.01.005.
4. Noufal MP, Abdullah KK, Niyas P, Nambiar VR. Analysis of influence of error in
angular settings of couch and collimator on the dosimetric and radiobiological
parameters in VMAT plans. J Med Imaging Radiol Sci. 2016;48(2):166-177.
http://dx.doi.org/10.1016/jmir.2016.10.012.
5. Matuszak M, Grills I, Martinez A. Clinical applications of volumetric modulated arc
therapy. Int J Radiat Onc Biol Phys. 2010;77(2):608-616.
http://dx.doi.org/10.1016/j.jrobp.2009.08.032.
6. Tas B, Bilge H, Ozturk ST. An investigation of the dose distribution effect related
with collimator angle in volumetric arc therapy of prostate cancer. J Med Phys.2016;
41(2):100-105. http://dx.doi.org/10.4103/0971-6203.181635.
7. Andersen, A., Johnson, C., Bartlett, G. and Das, I. SU-G-BRC-04: collimator angle
optimization in volumetric modulated arc therapy. Med. Phys.2016;43(6):3627.
http://dx.doi.org/10.1118/1.4956894.
8. Feuvret L, Noel G, Mazeron J, Bey P. Conformity index: a review. Int J Radiat Onc
Biol Phys. 2006;64(2):333-342. http://dx.doi.org/10.1016/j.ijrobp.2005.09.028.
9. Kataria T, Sharma K, Subramani KP, Bisht S. Homogeneity Index: an objective tool
for assessment of conformal radiation treatments. J Med Phys. 2012;37(4):207-213.
http://dx.doi.org/10.4103/0971-6203.103606.
10. Gong Y, Wang J, Bai S, Jiang X, Xu F. Conventionally-fractionated image-guided
intensity modulated radiotherapy (IG-IMRT): a safe and effective treatment for
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cancer spinal metastasis. Radiat Onc. 2008;3(1):11. http://dx.doi.org/10.1186/1748-

717X-3-11.
11. Kinhikar R, Ghadi Y, Sahoo P, et al. Dosimetric comparison of three-dimensional
conformal radiotherapy, intensity modulated radiotherapy, and helical Tomotherapy
for lung stereotactic body radiotherapy. J Med Phys. 2015;40(4)190-197.
http://dx.doi.org/10.4103/0971-6203.170792.
12. Agnew C, McGarry C. A tool to include gamma analysis software into a quality
assurance program. Radiotherap Onc. 2015;118(3):568-573.
http://dx.doi.org/10.1016/j.radonc.2015.11.034.
13. Hong D, Bundalevski I, Wong K, Mokhtar BE, Ashmalla H, Parameritis J, Kyriacon
A. Impact of collimator angle deliverability of volumetric modulated arc therapy
(VMAT). Int J Radiat Onc Biol Phys. 2016;96(2):E632.
http://dx.doi.org/10.1016/j.ijrobp.2016.06.2211.
14. Kyriacou D. The enduring evolution of the p value. JAMA. 2016;315(11):1113-1115.
http://dx.doi.org/10.1001/jama.2016.2152.
15. QuickCalcs Calculator.GraphPad Software
Website.http://www.graphpad.com/quickcalcs/pvalue1.cfm.
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Figures

99.16%
99.15%
99.14%
99.13%
Percentages

99.12%
99.11%
99.10%
99.09%
99.08%
99.07%
99.06%
CI AVG

330 345 315 300 285 270

Figure 1. The average CI for each of the computed counter-clockwise beams.

1.048

1.0475
Homogenetity Indices

1.047

1.0465

1.046

1.0455
HI AVG

330 345 315 300 285 270

Figure 2. The average HI for each of the computed counter-clockwise beams.

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Figure 3. Pinnacle Treatment Planning System (TPS) scorecard generated as a method of plan
evaluation of the initial plan in the Pinnacle TPS. These goals were also used in the Eclipse
initial plan evaluations. However, these goals had to be hand generated from the dose volume
histogram (DVH).
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Tables
Table 1. Optimization parameters used at the start of treatment planning.
Primary Goal Secondary Goal
Region Of Interest Type Dose(cGy) Volume Dose(cGy) Volume
PTV Minimum DVH (%) 7920 99% 7920 95%
PTV Minimum DVH (%) 7366 99% 0 0%
PTV Maximum DVH (cm3) 8474 0.1 cm3 8712 0.1 cm3
Rectum Maximum DVH (%) 8200 5% 0 0
Rectum Maximum DVH (%) 5000 50% 0 0
Rectum Maximum DVH (%) 7000 20% 0 0
Bladder Maximum DVH (%) 4700 53% 0 0
Bladder Maximum DVH (%) 6200 25% 0 0
Small Bowel Maximum DVH (cm3) 5000 0.1 cm3 5400 0 cm3
Left Femoral Head Maximum DVH (cm3) 4500 0.1 cm3 5000 0 cm3
Right Femoral Head Maximum DVH (cm3) 4500 0.1 cm3 5000 0 cm3

Table 2. Calculated averages for each parameter combining data from Eclipse and Pinnacle.
Parameter 345 330 315 300 285 270
Rectum
Maximum Dose (cGy) 8363 8364 8385 8382 8403 8409
Mean Dose (cGy) 3943 3943 3950 3934 3946 3972
Bladder
Maximum Dose (cGy) 8406 8399 8385 8382 8403 8409
Mean Dose(cGy) 3060 3014 3950 3934 3946 3972
Left Femur
Maximum Dose (cGy) 3514 3362 3571 3597 3611 3514
Mean Dose (cGy)) 1426 1359 1448 1464 1448 1393
Right Femur
Maximum Dose (cGy) 3379 3511 3394 3521 3559 3422
Mean Dose (cGy) 1426 1359 1448 1464 1448 1393
PTV
Maximum Dose (cGy) 8539 8522 8517 8502 8508 8518
Minimum Dose (cGy) 7318 7277 7313 7287 7291 7284
Mean Dose (cGy) 8176 8174 8180 7291 7284 8178

Table 3. Calculated averages of CI, HI, intermediate dose spillage, and gamma values for each
angle combining the data from Eclipse and Pinnacle.
Parameter 345 330 315 300 285 270
CI 0.9911 0.9909 0.9914 0.9909 0.9910 0.9915
HI 1.0478 1.0469 1.0475 1.0466 1.0468 1.0464
ID 4.0797 4.0855 4.0841 4.1317 4.1875 4.1615
Gamma Value 78.100 80.0800 82.3800 82.7000 81.1300 80.7400