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A Dosimetric Study using Split X-Jaw Planning Technique for the Treatment of
Endometrial Carcinoma

Jeanette Keil, BS, CMD, RT(R)(T) Joanne Carda, BS, RT(R)(T); Jade Reihart, BS, RT(T);
Marjorie Seidel, CMD, RT(R)(T); Nishele Lenards, PhD, CMD, RT(R)(T), FAAMD; Ashley
Hunzeker, MS, CMD; Matthew Tobler, CMD, RT(T)

ABSTRACT

The aim of this retrospective study was to determine if the split x-jaw planning technique could
be used with Varian linear accelerators to improve plan conformity and limit dose to organs at
risk (OAR) for planning target volumes (PTVs) that require field sizes larger than the 15 cm
extent of the multi-leaf collimator (MLC) in the x-jaw position. Traditional planning techniques
include limited and open x-jaw methods. The study population included 20 randomly selected
patients with endometrial carcinoma. Treatment plans for each patient were designed using split,
limited, and open x-jaw volumetric modulated arc radiotherapy (VMAT) for comparison
purposes. Dose statistics including the PTV conformity index (CI) and dose to OAR were used to
evaluate plan performance. Results showed the split x-jaw planning method had the most
consistent CI (0.980 ± 0.002), followed by the open (1.005 ± 0.003), and the limited (1.013 ±
0.005) techniques. On average, the split method better spared the OAR. In comparison to the
limited and open techniques, the split method reduced the dose to the bowel by 3.8%, rectum by
3.2%, sigmoid by 2.1%, right femoral head by 3.5%, and left femoral head by 3.9%. The split
and open techniques showed comparable bladder results and were superior over the limited
method. The monitor units (MUs) were highest with the split method leading to increased
treatment times. The study concluded the split x-jaw planning technique should be used with
Varian linear accelerators to produce superior VMAT plans for PTVs larger than the maximum
extent of the MLC in the x-jaw direction.
Keywords: Split x-jaw planning technique, volumetric modulated arc radiotherapy (VMAT),
large planning target volume (PTV), Varian multi-leaf collimator (MLC), endometrial radiation
therapy
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Introduction
Linear accelerators are highly technical machines used to deliver radiation for cancer treatments.
The main goal of this technology is to provide adequate dose to a target volume to eliminate
cancer cells while minimizing exposure to surrounding healthy tissues.1 Two aspects of the
mechanical design that allow for beam shaping are the collimator jaws and the multi-leaf
collimator (MLC). The collimator jaws are solid tungsten blocks used to create rectangular
treatment fields, while the MLC are comprised of individual movable leaves to assist in
additional beam shaping. A novel treatment technique utilizing the MLCs is volumetric
modulated arc radiotherapy (VMAT).2 Volumetric modulated arc radiotherapy allows for high
quality planning and more efficiency than 3D or fixed intensity modulated radiotherapy (IMRT)
techniques.
Although VMAT enhances radiotherapy by increasing tumor volume conformity, there
are limitations. The MLC leaves in the Varian linear accelerator travel on a carriage that allows a
maximum x-jaw extent of 15 cm. Overextension when using VMAT reduces the modulation
level and results in poor target dose distribution and OAR sparing.3 Unlike fixed IMRT, which
allows carriage shifts to provide coverage for large PTVs, VMAT requires a single carriage
position due to the constant motion of the gantry. According to Huang et al,3 when the field size
is set to < 15 cm, anywhere inside the field can be modulated by both sides of the MLC to
achieve better optimization results. When the field size is > 15 cm, some areas in the field can
only be reached by one side of the MLC, prohibiting adequate modulation (Figure 1). Therefore,
to achieve adequate dose coverage and better OAR avoidance, the x-jaw should be limited to 15
cm or less.1, 4-6
Planning target volumes for endometrial carcinoma are extensive and include the gross
tumor volume (GTV), clinical target volume (CTV), and margin for uncertainties in treatment
planning and delivery; specifically, setup error and movement. According to the Radiation
Therapy Oncology Group (RTOG) 0921,6 the CTV is defined as the region at risk for harboring
potential microscopic disease including the internal, external, and common iliac lymph nodes to
the level of L4/5. The PTV is generated with a 0.7 cm margin around the CTV resulting in a
widespread target volume. In conventional VMAT, the typical field size along the x-jaw is 20 -
25 cm to cover the entire PTV.3 Due to the physical limitation of the MLCs in Varian linear
accelerators, treatment planning for these cases can become problematic.
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Current VMAT treatment planning methods include open and limited x-jaw techniques as
previously investigated by Zhang et al.4 In open x-jaw plans, the jaw width is automatically set to
cover the entire target volume. These fields typically extend over the 15 cm MLC limitation and
yield reduced modulation and plan conformity. The limited x-jaw technique offers an advantage
in that the jaw width remains constant at a symmetric 15 cm (X1= +7.5, X2= -7.5), resulting in
better modulation, dose distribution, and OAR sparing.6 However, due to the limited field size,
there may be areas where large PTVs are only partially covered. Both the limited and open
methods offer opportunities for improvement.
The split x-jaw planning technique divides the open field into 2 separate fields with
overlap on each side of the central axis. The result is a total of 4 treatment arcs encompassing the
entire PTV. Each field is limited to 15 cm to offer increased modulation and conformity. In
preliminary research for this study, the split x-jaw method showed positive results in head and
neck treatment planning; however, exploring the versatility of the technique in other areas of the
body, such as the abdomen and pelvis, is necessary. The aim of this paper was to expand upon
research conducted by Zhang et al,4 and investigate the benefits of the split x-jaw planning
technique in the treatment of endometrial carcinoma.
Methods and Materials
Patient Selection & Setup
Twenty patients diagnosed with endometrial carcinoma receiving radiation treatments
were retrospectively selected for this study. Selection criterion included an established PTV
requiring an x-jaw greater than 19 cm for adequate coverage. Based on the RTOG 0921 protocol,
the CTV was contoured and expanded by 0.7 cm to create the PTV. Boost plans were not
included in this particular study.
The patients were imaged in the treatment position with a Siemens CT scanner using 0.3
cm slice thickness. Each patient was positioned head first and supine with a vac fix cushion
under the legs for immobilization. The arms were placed high on the chest holding a blue ring for
patients without elective nodal treatment. Cases receiving regional nodal irradiation were
scanned with the arms up on a wing board. The attending radiation oncologist placed a vaginal
marker for delineation in 19 of the 20 cases and 3-point reference marks were created for setup
reproducibility. The scan parameters included anatomy from the second lumbar vertebral body
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through mid-femur in 14 cases. The remaining 6 patients required more margin on the superior
aspect of the imaging study due to elective paraaortic nodal treatment.
Contouring
Following simulation, patient datasets were imported into the Eclipse 13.5 treatment
planning system (TPS) for delineation of target volumes and OAR. Target volumes were created
by the attending radiation oncologist to include the GTV and CTV according to the RTOG 0921
protocol guidelines. The CTV was contoured and expanded uniformly by 0.7 cm to create the
PTV for adequate treatment margin. The OAR were contoured by the medical dosimetrist to
include the bladder, rectum, sigmoid, small and large bowel, and right and left femoral heads
according to RTOG 0921 protocol guidelines. The kidneys were contoured in patients receiving
paraaortic nodal irradiation. Prior to treatment planning for this study, image datasets were
evaluated by the planning medical dosimetrist, and contours were modified on an as needed basis
to adhere to RTOG protocol guidelines.
Treatment Planning
For each case, 3 separate treatment plans were generated to include the open, limited, and
split x-jaw planning techniques utilizing the Eclipse 13.5 TPS. A single medical dosimetrist
completed all 60 plans for this study to reduce variability. Patients were prescribed a dose of 45
Gy in 25 fractions and boost plans were not included in this study. The Eclipse Arc Geometry
Tool was used to place the isocenter in the center of the PTV and plans were generated for a
Varian Truebeam linear accelerator with beam energies of 6MV and a maximum dose rate of
600 MU/min.
The open and limited techniques utilized coplanar dual arcs (clockwise rotation from
181° to 179° and counter-clockwise rotation from 179° to 181°) with couch rotation 0°. The
collimators were set to 15° and 345° respectively to minimize contribution of the tongue-and-
groove effect to the dose. The specific collimator angles were selected to minimize the width of
the x-jaw as much as possible without compromising PTV coverage. The field size for the open
x-jaw method was created automatically using the Eclipse Arc Geometry Tool, expanding the x-
jaw to encompass the entire target volume (Figure 2a). The limited x-jaw method utilized the
same isocenter but restricted the total x-jaw expansion to a symmetric 15 cm (X1= +7.5, X2= -
7.5) (Figure 2b).
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The split x-jaw technique employed 4 arcs (2 clockwise rotations from 181 to 179° and 2
counter-clockwise rotations from 179° to 181°) with couch rotation 0°. The collimators were set
to 15° and 345° respectively. The first 2 fields were developed by using the Eclipse Arc
Geometry tool, expanding the jaws to cover the entire PTV. These fields were duplicated
resulting in 2 clockwise and 2 counter-clockwise arcs. The clockwise arcs were named 1 and 1A
respectively. Beginning with field 1, the X2 jaw was closed so the maximum width was 15 cm
resulting in coverage of the right side of the PTV (Figure 3a). Using field 1A, the X1 jaw was
closed so the maximum width was 15 cm resulting in coverage of the left side of the PTV
(Figure 3b). The process was repeated to create the counter-clockwise arcs with names 2 and 2A.
Although the split x-jaw method utilized 4 arcs, it essentially divided the open x-jaw fields in
half and limited each to 15 cm, therefore, encompassing the same volume as the open field, but
creating an advantage of increased modulation with the 15 cm field sizes.
The 3 VMAT plans were produced using equivalent optimization objectives to reduce
variability. The initial objectives were based on the RTOG 0921 protocol constraints. Dose-
volumetric parameters included the percentage of bowel and rectum that received a dose of 40
Gy (V40), percentage of bladder that received 45 Gy (V45), and percentage of the left and right
femoral heads that received 35 Gy (V35). The specific constraints for each structure were as
follows: bowel V40 < 30%, rectum V40 < 60%, bladder V45 < 35%, and left and right femoral
heads V35 < 15%. The PTV was evaluated based on V45 > 95% and the percentage of PTV that
received a dose of 49.5 Gy (V49.5), V45.9 < 110%. These objectives were first applied to the open
plan optimization and modified to achieve acceptable parameters. The open method was selected
to create the base plan because it had the least opportunity for modulation. The ideal
optimization objectives were then applied to the limited and split plans with no modification.
Additionally, the normalization to the PTV was consistent among the 3 planning techniques with
100% of the prescription covering 95% of the PTV. Treatment planning goals included satisfying
target coverage while meeting OAR constraints as identified by the RTOG 0921 protocol.
Plan Comparison
The open, limited, and split planning methods were evaluated primarily based on plan
conformity and OAR sparing. Data was gathered and recorded for each plan based on the Eclipse
TPS dose statistics. Plan conformity was determined using the Eclipse TPS CI. The value is
defined as the volume encompassed by the prescription isodose region divided by the target
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volume and a value of 1.0 represents the ideal level of plan conformity. Evaluation indicators for
OAR were recorded based on quantitative data from the dose-volume histogram (DVH) based on
RTOG 0921 guidelines.
Secondary plan comparison data was based on various parameters including the
maximum dose, the volumes of the 30%, 50%, and 105% isodose regions, and the total MUs.
The maximum dose for each plan was restricted to the PTV and was defined as a volume that
was 0.03 cc or larger. The volume of the 30%, 50%, and 105% isodose regions were documented
in cm3 and used as measures of plan conformity. The total MUs were determined by adding the
MUs from each treatment field located within the identified plan. All secondary parameters were
recorded based on the Eclipse TPS dose statistics.
Results
All 3 planning methods were capable of delivering 100% of the prescription dose to 95%
of the PTV for the entire study sample. The time required to generate the fields for the open and
limited plans was similar, while the split method needed a few extra minutes to duplicate and
divide the fields, creating 2 additional arcs. On average, the open method required several
optimization iterations to achieve an acceptable dose distribution because it was utilized as the
base plan. This is not a reflection of the quality of the open plan, as additional iterations would
be required for the split and limited techniques if they were considered the base plan.
Conformity and OAR Sparing
Target coverage among the 3 planning methods was evaluated based on plan conformity.
The split technique showed the most consistent PTV conformity (0.98 ± 0.002) followed by the
open method (1.005 ± 0.003). The limited technique produced the widest range (1.013 ± 0.005).
The split technique also provided better OAR sparing. In comparison to the limited
technique, the split method reduced the mean dose to the bowel by 4.0%, rectum by 3.4%,
sigmoid by 2.2%, right femoral head by 3.5%, and left femoral head by 3.9%. The mean dose
reduction between the split and limited plans was statistically significant (p < 0.0005) for the
bowel, rectum, and sigmoid (Table 1) with 95% confidence. The split technique planned to
deliver 64.0 - 166.5 cGy less to the bowel, 84.5 - 156.0 cGy less to the rectum, and 37.7 - 124.8
cGy less to the sigmoid compared to the limited method (Figure 4). The split technique also
showed improvement over the open method, limiting the bowel by 3.8%, rectum by 3.2%,
sigmoid by 2.1%, right femoral head by 4.5%, and left femoral head by 6.3%. The mean dose
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reduction for the bowel, rectum, sigmoid, left femoral head (p < 0.0005), and right femoral head
(p = 0.001) was statistically significant. With 95% confidence, the split technique planned to
deliver 58.4 - 158.4 cGy less to the bowel, 75.6 - 166.5 cGy less to the rectum, 36.7 - 115.7 cGy
less to the sigmoid, 47.2 - 181.9 cGy less to the right femoral head, and 75.0 - 243.6 cGy less to
the left femoral head. The split technique also better spared the bladder with a 7.0 to 90.0 cGy (p
= 0.019) decrease over the limited method however, the open and split technique showed
comparable results and data that was not statistically significant.
Dose Parameters and MU
The split technique provided the lowest maximum dose in all 20 cases with a mean of
108.8% ± 0.3%, followed by the open with 110.4% ± 0.3%, and the limited with 112.3% ± 0.6%.
In addition, the volume of the 105% isodose region was minimal using the split planning method
with a mean of 195.75 cc compared to the limited and open techniques with 687.89 cc and
524.79 cc respectively. The volume of the 105% isodose line was 353.6-630.7 cc (p < 0.0005)
less in the split plan compared to the limited plan and 219.5-438.6 cc (p < 0.0005) less compared
to the open plan. The volume of the 50% isodose region was also considered and smallest in the
split plans with 5753.16 cc compared to the limited and open techniques with 5878.5 cc and
6036.64 cc respectively. The volume of the 30% isodose region was comparable among the 3
planning techniques.
The mean MUs in open, limited, and split methods reflected plan modulation. As the
ability to modulate increased, the MUs also increased. As such, the MUs were highest in the split
plans (mean 706 ± 22 MU), intermediate in the limited plans (mean 650 ± 16 MU), and lowest in
the open plans (mean 583 ± 21 MU).
Discussion
The aim of this retrospective study was to determine if the split x-jaw planning technique
should be used with Varian linear accelerators to improve plan conformity and limit dose to
OAR in PTVs that require field sizes larger than the 15 cm extent of the MLC in the x-jaw
position. According to Varian Medical Systems (Varian representative, oral communication,
September 2018), no formal treatment planning recommendations are indicated for large PTVs;
however, the user should be cognizant of the 15 cm modulation limitation. The preliminary
results from this study expanded upon the research completed by Zhang et al,4 comparing the
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limited and open planning techniques. The split x-jaw method showed superior results to both
the limited and open planning techniques in this study.
Over the course of this retrospective study, the split x-jaw technique delivered the most
consistent plan conformity. Dividing each open field into 2 arcs and restricting the field sizes to
15 cm lead to benefits over the open and limited planning methods. First, the PTV remained
within the dual arc fields over the entire treatment duration resulting in better dose distribution
and target coverage. The limited method x-jaw was set to 15 cm, leaving portions of the PTV
partially covered, resulting in reduced plan conformity. Although the open planning method
included the entire PTV, the field sizes were well beyond the 15 cm limitation of the MLCs,
yielding poor modulation and dose distribution. In addition, the split beam technique had an
average CI less than 1.0 and provided an opportunity to normalize the plan with better coverage
clinically.
The split method also showed better results in sparing OAR. Dose to the bowel, rectum,
sigmoid, and left and right femurs were considerably reduced using this technique due to
increased modulation. The limited method was not capable of shielding OAR regions outside of
the MLC leaf span, resulting in higher dose. Conversely, the open method could not provide
adequate modulation to block the OAR, leading to higher dose.
An aspect to consider with the split planning technique is 4 treatment arcs compared to 2
arcs using the open and limited planning methods. The additional arcs resulted in an increase in
MUs and treatment time. Patients that have difficulty holding the setup position for extended
periods of time may not tolerate the split planning technique. The open and limited planning
methods were similar with respect to MUs and treatment time. Another consideration with
increased MUs is the amount of low dose radiation to the surrounding normal tissue, which
potentially increases the risk of secondary malignancies. In comparison to the open and limited
methods, the split technique provided the smallest 50% isodose region and a comparable 30%
isodose region. Therefore, there is no added concern of secondary malignancy with the split
planning method despite more treatment arcs and MUs. The split technique also reduced high
dose areas delivering the smallest 105% isodose region and lowest maximum dose.
Conclusion
Challenges with current treatment planning techniques used with Varian linear
accelerators for PTVs larger than the 15 cm extent of the MLC in the x-jaw position offer
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opportunities for improvement. The limited x-jaw planning method field size was set to a
symmetrical 15 cm, leaving areas of the PTV partially covered. The open technique extended the
x-jaw past the 15 cm limitation and resulted in subpar modulation. With large PTVs, both OAR
sparing and plan conformity suffer negative effects using the limited and open planning methods.
Based on the results of this retrospective study, the split planning technique provided dosimetric
benefits for PTVs larger than the capable extent of the MLCs in Varian linear accelerators. The
split beam technique had an average CI less than 1.0 and provided an opportunity to normalize
the plan with better PTV coverage clinically. Investigation of a CI less than 1.0 with the split x-
jaw planning technique would be a good topic for additional research. The split technique
yielded superior target dose distributions and spared OAR more effectively than the limited and
open methods. In addition, the split technique reduced the 50% and 105% isodose regions, which
significantly improved plan conformity. The low dose regions were comparable among the 3
planning methods offering no additional concern for secondary malignancies from the split
planning technique.
One of the limitations of this study was the limited sample size. Therefore, future
research should focus on increasing the study population. Based on research results from the
current study and by Zhang et al,4 it is recommended to eliminate the open planning method and
examine only the split and limited techniques moving forward. In addition, the split x-jaw
treatment planning technique should be applied to other areas of the body with large PTVs, such
as the head and neck, abdomen, and pelvic regions, to explore versatility.

Acknowledgment
We would like to express our thanks to Dr. David Reineke, Carsten Hiltgen, Mitchell Maegaard,
and Laura Peterman of the UWL Statistical Consulting Center for their contributions to the
statistical analysis and interpretation of statistical results.
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References
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of volumetric modulated arc therapy. J Korean Phys Soc. 2015;67(1):243-247.
http://dx.doi.org/10.3938/jkps.67.243
3. Huang B, Fang Z, Huang Y, et al. A dosimetric analysis of volumetric-modulated arc
radiotherapy with jaw width restriction vs 7 field intensity-modulated radiotherapy for
definitive treatment of cervical cancer. Br J Radiol. 2014;87(1039):20140183.
https://dx.doi.org/10.1259/bjr.20140183
4. Zhang WZ, Lu ZY, Chen JZ et al. A dosimetric study of using fixed-jaw volumetric
modulated arc therapy for the treatment of nasopharyngeal carcinoma with cervical lymph
node metastasis. PLoS One. 2016;11(5):e0156675.
http://dx.doi.org/10.1371/journal.pone.0156675
5. Rossi M, Boman E, Skytta T, Kapanen M. A novel arc geometry setting for pelvic
radiotherapy with extensive nodal involvement. J Appl Clin Med Phys. 2016;17(4):73-85.
http://dx.doi.org/10.1120/jacmp.v17i4.6028
6. Vieillot S, Azria D, Lemanski C, et al. Plan comparison of volumetric-modulated arc therapy
(RapidArc) and conventional intensity-modulated radiation therapy (IMRT) in anal canal
cancer. Radiat Oncol. 2010;5(1):92. http://dx.doi.org/10.1186/1748-717X-5-92
7. Viswanathan AN, Moughan J, Miller BE, et al. NRG oncology/RTOG 0921: a phase II study
of postoperative intensity modulated radiation therapy (IMRT) with concurrent cisplatin and
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cancer. Cancer. 2015;121(13):2156-2163. https://dx.doi.org/10.1002/cncr.29337
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Figures

Figure 1. The field size is >15 cm and the MLCs crossing the central axis are reaching the
maximum extent leaving areas in the field that can only be reached by one side of the MLC. The
consequence is reduced modulation in these areas.
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Figure 2. The open plan was created automatically using the Eclipse Arc Geometry Tool to
expand the x-jaw to encompass the entire PTV (a). The limited technique restricted the total x-
jaw expansion to a symmetric 15 cm (X1= +7.5, X2= -7.5) to account for the MLC limitation
(b).

Figure 3. The split method was created by using the Eclipse Arc Geometry Tool to expand the x-
jaws to cover the entire PTV and duplicating resulting in 2 fields named 1 and 1A. Beginning
with field 1, the X2 jaw was closed to the maximum width was 15 cm resulting in coverage of
the right side of the PTV (a). For field 1A, the X1 jaw was closed so the maximum width was 15
cm resulting in coverage of the left side of the PTV (b).
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Figure 4. The mean dose to the OAR was the lowest using the split x-jaw planning method
compared to the open and limited techniques.
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Tables

Table 1. Results summary of treatment parameters including OAR, MU, Maximum dose and
isodose volumes (V50, V105). All comparisons reference a 95% confidence interval and values
indicate the upper and lower bound limits of the collected data.
Split vs. Split vs.
p-value p-value
Open Limited
58.4-158.4
Bowel (cGy) <0.0005 64.0-166.5 less <0.0005
less
75.6-166.5
Rectum (cGy) <0.0005 84.5-156 less <0.0005
less
36.7-115.7
Sigmoid (cGy) <0.0005 37.7-124.8 less <0.0005
less
37.2 less to
Bladder (cGy) NS 7.0-90.0 less 0.019
0.4 more
47.2 to 178.1 less to
Right Femoral Head (cGy) 0.001 NS
181.9 less 3.9 more
75.0 to 213.5 less to 21
Left Femoral Head (cGy) <0.0005 NS
243.6 less more
57.2 to 13.2 to 98.8
MU <0.0005 0.008
188.8 more more
0.010 to 0.024 to 0.047
Maximum Dose (%) <0.0005 <0.0005
0.022 less less
219.5 to 353.6 to 630.7
105% IDL (cc) <0.0005 <0.0005
438.6 less less
209.1 to 45.3 to 205.3
50% IDL (cc) <0.0005 0.002
357.8 less less
a
NS stands for not statistically significant.