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Comparison of IMRT and VMAT treatment techniques and their effects on V5 Lung doses
Amber Mehr, B.S., Andrew Edel, B.S, Jenny Huang, B.S., R.T.(T), Ruha Siddiqui, B.S.,
Ashley Hunzeker, M.S., C.M.D., Nishele Lenards, R.T.(R)(T), M.S., C.M.D., FAAMD

ABSTRACT

Keywords:

Introduction:
In the past 3D Conventional Radiation Therapy planning was primarily used for lung
treatments and dose constraints were based on Dose Volume Histograms (DVHs) of these
plans.1Through advancements in technology, Volumetric Modulated Arc Therapy (VMAT) and
Intensity Modulated Radiation Therapy (IMRT), are now being used for lung
treatment planning.2 The advanced treatment planning techniques have led to more entry points
for radiation dose through the use of multiple beams and continuous arcs. In retrospect, this has
created a risk for increasing the percentage of the lung volume receiving a dose of 5Gy or more
(lung V5).3 The increased lung dose is a concern for patients because when the V5 dose increases,
there becomes a higher risk for radiation pneumonitis and other complications.3,4,5
Past studies have shown that when comparing IMRT to VMAT, dynamic arc therapy
produces significantly greater low lung dose (V5) exposure as Planning Target Volume (PTV)
size increases compared to static IMRT.2,5 Previous research studies have proposed that V5 is not
predictive of radiation pneumonitis, but studies have not indicated if V5 levels are higher when
dose is delivered with dynamic arcs. Graham et al. utilized the percentage of lung volume
receiving a dose of 20Gy or more (lung V20) to evaluate the risk of pneumonitis.1 However,
looking at this criterion alone may not be as predictive as previously thought. Data now suggests
that lung V5 must be looked at in addition to V20.2,3
The aim of the current research was to determine if lung dose is significantly higher in
VMAT treatments versus IMRT and compare the two planning techniques to determine which
treatment technique provides better PTV coverage. Another component of the research was
looking at how well IMRT and VMAT planning prevented dose to organs at risk (OAR). The
study looked at the spinal cord, lungs, heart, and esophagus and determined if one planning
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technique was better at sparing an organ when compared to the other. This study showed the
differences in VMAT and IMRT planning when treating centrally located lung tumors.
Materials and Methods:
Patients 
The patient data used for the treatment comparison were collected from three different
cancer centers. All patients had centrally located lung tumors with a PTV between 40-400cc. To
be considered for the study, the patients had to be treated after 2015 and prescribed to
a certain dose range. The tumors ranged in the type of cancer and progression they obtained. This
meant all stages and diagnoses were considered if they met the previous criteria. There were
various factors that would prevent patients from being part of the study. If a patient’s tumor was
located laterally within the lung instead of centrally the patient would not be considered. Patients
that had any prior radiation treatments were considered ineligible for the study. Another
important factor was to be cognizant of the previous plan using V5 as an optimization parameter.
This was excluded from this study to prevent bias within the results. Controlling this within the
study was essential because if the V5 was used as an optimization parameter, the plan could not
be used to determine if IMRT or VMAT planning technique resulted in greater V5 dose.
Patient Setup
For treatment, all the patients were positioned in a similar fashion. Patients were setup in
the supine head first position during their CT simulation. The patient’s arms were placed over
their heads using a T-Bar device. The T-Bar device was utilized to remove the patient’s arms
from radiation treatment area as well as lowering the dose that the upper extremities would
receive. A Vacuum-Lock bag was placed underneath the patient’s chest and arms to provide
stability and comfort. Lastly, an elastic band was placed around their feet to help limit patient
mobility during the scan and treatments by eliminating fidgeting. This same positioning would
be recreated for their radiation treatments daily. Once the CT scan was performed, the isocenter
was set by the radiation oncologist and medical dosimetrist within the clinic. The radiation
therapist then positioned the patient using positioning lasers within the CT. This was done to
align the patient at the isocenter that the physician had set. The patient was then marked with
three tattoos at the locations where the positioning lasers intersected. These tattoos were used
during treatment to ensure reproducibility and patient alignment to the isocenter.
Contouring
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After the CT simulation was performed, the patient's images were uploaded into either
Pinnacle or Eclipse treatment planning systems to be contoured by the radiation oncologists and
medical dosimetrists. The radiation oncologists were responsible for contouring the target
volumes gross tumor volume (GTV), clinical target volume (CTV) and PTV. The GTV was
contoured first by the physician. The GTV was created around the cancerous tissue determined
by imaging and the radiation oncologist. The GTV was then expanded 0.7 cm in all directions to
create the CTV. To create the PTV, the CTV was expanded 1.0 cm superiorly and inferiorly and
0.5 cm lateral and medially coinciding with the Radiation Oncology Group (RTOG) 0617
Protocol.6 Once the contours were completed, the plan was given to the medical dosimetrists to
contour. The medical dosimetrists contoured the thoracic organs at risk (OAR) following RTOG
0617 protocol to include spinal cord, lungs, esophagus, and heart (Table 1).6
Treatment Planning 
Treatment planning was performed using IMRT and VMAT techniques within the
Pinnacle or Eclipse treatment planning systems. Applying proper technique depended on the
tumor size, tumor location, OAR and dose-tolerance criteria. The medical dosimetrists used 6
megavoltage energy photon beams for both the IMRT and VMAT plans involving the centrally
located lung tumors. The prescriptions ranged between 45 Gy-65 Gy for treatments but was kept
consistent when re-planning using the different treatment technique for the current study.
IMRT treatments take more time because the patient and radiation therapists must wait
for the gantry to be setup at the appropriate beam angle. The medical dosimetrists used 5-
9 beams for each IMRT plan.4 The beams were placed at angles to avoid the OAR, specifically to
avoid the spinal cord. IMRT improves dose conformity when compared to standard three-
dimensional treatments. However, a minor draw-back to this form of planning is the lengthy
delivery time.2 .
VMAT produces highly conformal dose distribution, improves the delivery efficiency by
reducing treatment time and produces accurate dosimetric calculations.2 The VMAT beams were
arranged as partial arcs, single arcs, two partial arcs or two full arcs with varying collimator
angles. The beams were planned with different rotational directions, clockwise (CW) and counter
clockwise (CCW). The arcs and collimator angles were chosen to avoid OAR while maintaining
the best coverage of the PTV.
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To determine the constraints for the OAR used for planning and optimization, the
radiation oncologist referred to RTOG 0617 for creating the IMRT and VMAT treatment plans.
The plans would be created by optimizing to lung(s), spinal cord, esophagus, heart constraints,
and while simultaneously optimizing to obtain PTV coverage (Table 1). Once an IMRT and a
VMAT plan was created for each patient, the plans would be compared to identify the
differences.
Plan Comparisons 
Plans using both VMAT and IMRT techniques from previously planned patients were
looked at for comparison purposes. Data were collected from each patient and anonymously
recorded for analysis. Each patient was evaluated for the percentage lung volume receiving 5Gy
or more (V5), and the data was recorded to help gain a better understanding of IMRT versus
VMAT treatment technique quality.
Plans were compared based on several other factors as well. The different techniques for
treatment planning were compared based on their coverage of the PTV. The techniques were
also related to each other to see how well each met the constraints. Each constraint was
compared between each plan, looking at the lungs, spinal cord, esophagus, and heart.
When evaluating the plans, the prescription dose used for each plan was considered
during the plan comparison. Patients receiving less dose would have OAR that received less dose
as well. To account for different prescriptions, the researchers looked at the differences between
the VMAT value and IMRT value for each OAR, PTV coverage and lung V5 dose in every
patient and used those differences to calculate the results.
Results:
When analyzing the IMRT and VMAT treatment plans, the PTV coverage decreased an
average of 1.92% when switching from VMAT technique to IMRT. The plans were compared
using a paired t-test, looking at the VMAT plan's PTV coverage minus the IMRT plan's PTV
coverage for each patient's plans. A paired t score of 2.5 was calculated from the plan
differences. This result validated that there was a significant difference between the IMRT and
VMAT planning strategies when it came to PTV coverage. Even though the IMRT plans had less
PTV coverage than the VMAT plans, the plans using the IMRT treatment technique still met
initial and alternative planning techniques for PTV coverage.
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The differences between doses to critical organs for each plan was also measured. The
percentage volume of lung receiving 30Gy or more (lung V30), percentage volume of lung
receiving 20Gy or more (lung V20), the maximum dose to the spinal cord in cGy, percentage
volume of esophagus receiving 35Gy or more (esophagus V35) and the percentage volume of
heart receiving 60Gy or more (heart V60) were all compared. All the organs met the constraints
set by the radiation oncologists for both IMRT and VMAT plans. T-tests were run for each OAR
to test the differences in the ability of IMRT and VMAT planning techniques to meet OAR
constraints. The t-values showed differences between techniques were not statistically
significant.
The final comparison between IMRT and VMAT planning techniques observed the V5 lung
dose. When calculating the difference between planning techniques, the V5 lung dose
decreased an average of 3.0% when re-planned with IMRT. A paired t-test was calculated and a
paired t-score of 1.34 failed to prove that this was a significant difference. A standard deviation
for difference in V5 dose was 6.7% between plans. This percentage means that between patients
the resulting V5 dose was highly variable.
Discussion:
Coverage of the lung tumor PTV decreased when using IMRT versus VMAT. For each
patient, the plan was normalized to meet the PTV coverage requirements. The difference
between VMAT planning and IMRT planning, was the number of gantry angles utilized by
VMAT during its motion through the arc. The more diverse angles lead to better PTV coverage
because of the increased accessibility to the PTV as well as the increased conformity. IMRT is
limited to the angles chosen by the medical dosimetrist and therefore has fewer entry points,
limiting the ways in which the dose can interact with the PTV.
All the OAR constraints were also met using both IMRT and VMAT. There was not a
significant difference in either planning technique's ability to reduce the dose to the OAR. This
allows medical dosimetrists to push organ doses well below their dose limits. If the constraints
were not being met during IMRT planning, the dosimetrist could increase priority in the
optimizer, rotate the collimators, adjust the arcs or beam angles and more to meet the OAR
constraints. Both treatment planning techniques make it easier for medical dosimetrists to limit
the dose received to critical organs.5
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When comparing the treatment strategies, the V5 lung dose for the VMAT plans was
statistically the same as the V5 dose for the IMRT plans. The greater number of beams used
during IMRT treatments, made the IMRT dose distribution considerably similar to the VMAT
dose distribution. As a result, the V5 lung dose for IMRT and VMAT plans was comparable.
Conclusion:
Through advancements in technology, IMRT and VMAT planning are now being used to
perform lung treatments. With the introduction of these techniques, the difference of V5 lung
dose needed more analysis due to its potential to cause pneumonitis. Patients with centrally
located lung tumors were selected and IMRT and VMAT plans were created to determine the
differences in coverage, OAR dose and V5 lung dose. When comparing IMRT and VMAT
treatment plans, there were differences found amongst both techniques. Planning with IMRT,
resulted in less PTV coverage but the strategy still limited dose to OAR and met V5 lung
constraints. Using VMAT, to plan for centrally located lung tumors, resulted in higher PTV
coverage while meeting dose limits. Both techniques were beneficial to the medical dosimetrists
because they were able to maintain coverage while limiting dose to critical structures due to
blocking and beam placement. The limitations for this study included the small sample size and
not including 3DCRT as one of the planning techniques for comparison.
For future studies, the number of beams used during IMRT should be limited to six to see
if there is a difference in the V5 lung dose in IMRT and VMAT treatment.4 Medical dosimetrists
should also look at IMRT planning versus 3DCRT and VMAT versus 3DCRT to see how much
the lung V5 dose has increased with planning technique advancements. Knowing the amount of
lung V5 dose a patient is receiving is important because increased low lung doses could lead to
future radiation damage.
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References
1. Graham MV, Purdy JA, Emami B, et al. Clinical dose-volume histogram analysis for
pneumonitis after 3D treatment for non-small cell lung cancer (NSCLC). Int
J Radiat Oncol Biol Phys. 1999;45(2):323-329.
https://dx.doi.org/10.1016/S0360-3016(99)00183-2
2. Li Y, Wang J, Tan L, et al. Dosimetric comparison between IMRT and VMAT in
irradiation for peripheral and central lung cancer. Oncol Lett. 2018;15(3):3735-3745.
https://dx.doi.org/10.3892/ol.2018.7732
3. Aaron A, Czerminska M, Jänne P, et al. Fatal pneumonitis associated with intensity-
modulated radiation therapy for mesothelioma. Int J Radiat Oncol Biol
Phys. 2006;65(3):640 – 645.
https://dx.doi.org/10.1016/j.ijrobp.2006.03.012
4. Helen H, Jauregui M, Zhang X, et al. Beam angle optimization and reduction for
intensity-modulated radiation therapy of non–small-cell lung cancers. Int
J Radiat Oncol Biol Phys. 2006;65(2):561–572.
https://dx.doi.org/10.1016/j.ijrobp.2006.01.033
5. Lievens Y, Nulens A, Gaber MA, et al. Intensity-modulated radiotherapy for locally
advanced non-small-cell lung cancer: a dose-escalation planning study. Int
J Radiat Oncol Biol Phys. 2011;80(1):306-313.
https://dx.doi.org/10.1016/j.ijrobp.2010.06.025
6. Bradley J, Choy H, Komaki R, et al. RTOG 0617: A randomized phase III
comparison of standard-dose (60 Gy) versus high dose (74 Gy) conformal
radiotherapy with concurrent and consolidation carboplatin/paclitaxel +/- cetuximab
(IND #103444) in patients with stage IIIA/IIIB non-small cell lung cancer. Lancet
Oncol. 2015(2):187-199.
https://dx.doi.org/10.1016/S1470-2045(14)71207-0
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Figures
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Tables

Table 1. The thoracic constraints used for patient treatment planning in IMRT and VMAT

Organ at risk Objectives

Spinal Cord Vmax (point dose) < 50 Gy

Vmax (0.03 cc) < 44-48 Gy

Lung V20 < 30-35%

V30 < 20-25%

Esophagus V45 < 33%
Heart V60 < 33%