1

Capstone Outline III: Evaluation of mixed energy partial arcs in volumetric modulated arc
therapy for anal cancers with lymph node involvement
Mikayla Eskens, Helen Nguyen, and Will Deere
University of Wisconsin – La Crosse

I. Abstract
A. This will be left blank until the end of the semester.
II. Introduction
A. While creating a radiation therapy treatment plan, medical dosimetrists are able to
utilize photons of varying energies depending on the depth of the planning target
volume (PTV).
1. Deep-seeded tumors require higher energy photons because of their ability
to penetrate through matter. Tumors that are more superficial require low
energy photons. This is also the case when skin irradiation is desirable.
2. Considering the typical patient habitus observed in many clinics today,
additional focus is placed on the dosimetric benefits in using higher
treatment energies.
3. A study comparing photon energies in prostate volumetric modulated arc
therapy (VMAT) treatments demonstrated lower relative integral dose,
monitor units, skin depth of maximum dose (D max), and bladder volume
receiving 30 Gy (V30) for the 10 MV plans versus the 6 MV plans.1
4. Though higher energies can be beneficial in reaching deep seated tumors,
photon energies higher than 10 MV are not recommended for VMAT
treatments due to the additional dose contributed from photoneutron
contamination.2
5. Additionally, 6 MV and 10 MV VMAT treatments were found to be more
beneficial than using 15 MV photons in a study by Yadav et al.3
6. Some cancers such as those found in the pelvis region range drastically in
depth from the skin surface; these can be difficult to treat and may
necessitate the use of multiple photon energies.
 2

7. One such treatment historically treated using multiple photon energies, is

anal cancers with lymph node involvement (AC-LNI).
B. Multiple treatment plan methods have been implemented in treating AC-LNI in
attempt to produce adequate PTV coverage while preventing organs at risk (OAR)
from receiving excess dose.
1. Before VMAT and dynamic intensity modulated radiation therapy
(IMRT) technology was available, AC-LNI was conventionally treated
with mixed energy three-dimensional conformal radiation therapy (3D-
CRT).
2. These mixed energy 3D-CRT treatment plans consisted of deep-
penetrating static beams (15 MV or 18 MV photons) and superficially
penetrating static beams (6 MV photons or various energies of electrons)
in order to treat both the deep seated anal tumor and superficial nodes
respectively.4,5
3. With the introduction of VMAT and IMRT, 3D-CRT became unsuitable
for treating AC-LNI.
4. Multiple studies, including those by Vieillot et al,6 Clivio et al,7 and
Franco et al8 support the current convention of VMAT as the optimal form
of treatment for AC-LNI.
5. Research in combining traditional methods, such as mixed energy
treatments, with the more advantageous VMAT therapy for pelvic cancers
has shown interesting results in recent years.
C. Research in using mixed energy VMAT planning for anal cancers has not been
explored, however recent studies show benefits in using mixed energy IMRT and
VMAT plans for other pelvic cancers, such as prostate cancer.
1. In one study, Park et al9 evaluated mixed energy treatments for prostate
patients undergoing IMRT, and concluded that using mixed energies for
IMRT prostate plans can enhance the overall quality of the plan by
reducing dose delivered to organs at risk (OAR).
 3

2. Another study by Momin et al10 showed that mixed-energy VMAT plans

could be used to improve dose conformity to the PTV, and further limit
dose delivered to OAR.
3. Shyam Pokharel11 also studied the dosimetric impact of mixed‐energy
VMAT plans, and concluded that mixed-energy VMAT could reduce
integral dose and minimize the dose to the rectum in bladder when used
for high-risk prostate cancer cases.
4. Lastly, Mcgeachy et al used an external optimizer to provide beam energy
as a degree of freedom in IMRT optimization processes and found that
plans could be dosimetrically improved through sparing dose delivered to
OAR.12
5. Through the results of the above studies, a need was presented for further
research into the viability of mixed energy VMAT planning for applicable
pelvic sites with a large range in treatment depth, such as AC-LNI.
D. Anal cancers with lymph node involvement may present dosimetric advantages if
treated with a mixed energy VMAT treatment.
1. Using different photon energies during radiotherapy is a method medical
dosimetrists implement in order to treat target volumes at various depths.
2. The large range in treatment depth from the skin in AC-LNI has
historically been treated using mixed energy 3D-CRT.
3. This practice of treating AC-LNI is no longer clinically conventional
because VMAT has been established as the optimal form of treatment.
4. Research in combining 3D-CRT mixed energy methods with VMAT
treatment has shown some benefits for simple pelvic cancers, but has not
been investigated for cancers with a large range in treatment depth, such
as AC-LNI.
5. The purpose of this study is to investigate the clinical applicability of
using mixed energy VMAT plans to treat AC-LNI in comparison to
conventional single energy VMAT plans.
III. Methods and Materials
Patients
 4

A. Patients with AC-LNI were considered for this study.

1. The patient demographic was collected from two clinical sites, and
consisted of 20 patients with AC-LNI.
2. The lymph node systems involved for the patients considered in this study
included the external iliac system, internal iliac system, and inferior
mesenteric system.
3. No patients with metastatic disease were included in this research.
4. All cases included in this research were evaluated retrospectively using the
patient’s CT image collected during the simulation process of their
treatment.
B. Computed Tomography scans from each patient’s simulation procedure were
collected.
1. All patients were simulated, planned, and treated in the supine position.
2. The CT images were taken head-first with the scanning field of view
(FOV) including the pelvic region, at 3 mm slice thickness.
3. Patients included from site 1 were simulated on a Siemens Somatom
Sensation Open CT machine, and were immobilized with a Civco Hipfix
Thermoplastic positioning tool.
4. Patients taken from site 2 were simulated on a Philips Big Bore CT
machine, and were immobilized using a Civco Vac-Lok cushions and a Q-
Fix indexing tool.
5. Contours were added to each patient’s CT image for the purpose of this
study.
Contouring
A. Treatment volumes including gross tumor volume (GTV), clinical target volume
(CTV) and planning target volume (PTV) were contoured by the radiation
oncologist who had treated the patient during their radiation therapy.
1. For the purpose of this study, all CTV volumes include a primary tumor
(GTV) with associated lymph nodes.
2. For the PTV, a 1 cm margin was added to the CTV.
 5

3. All other structures apart from the target volumes were contoured by a
medical dosimetrist.
B. Normal structures were contoured by a single medical dosimetrist responsible for
carrying out the planning in this study.
1. The structures included the skin, bladder, bowel bag, external genitalia or
vagina, left femur, and right femur.
2. In cases where the patient’s CT included contrast in the bowel, the
contrast was also contoured to allow for Hounsfield Unit (HU)
corrections.
3. A Truebeam Couch structure was also added to all CT images for
consistency during the planning process.
Treatment Planning
A. All patients in this study were prescribed a prescription treatment of 1.8 Gy over
25 fractions for a total of 45 Gy delivered.
1. This prescription was used for a curative intent, instead of palliative.
2. All parameters used for creating the treatment plans in this study remained
consistent between patients.
B. Three treatment plans were created for each patient on the Eclipse treatment
planning system by Varian.
1. These plans included one plan using 6 MV photons, one using 10 MV
photons, and one plan that used both 6 MV and 10 MV photons.
i. A 6 MV plan was created with a prescription of 1.8 Gy over 10
fractions, also a 10 MV plan was created with a prescription of 1.8
Gy over 15 fractions.
ii. These two plans were then summed in order to create the mixed
energy VMAT plan that delivered a total of 45 Gy over 25
fractions.
2. Each treatment plan used a VMAT technique with 2 arcs, each of which
covered 359°.
i. The collimator angle for the first arc was set to 10° and the
collimator angle for the second arc was set to 350°.
 6

ii. Collimator jaws were set to encompass the PTV structure with a
margin of 0.5-2 cm depending on the specific jaw.
C. Optimization structures were contoured by the medical dosimetrist responsible for
carrying out the planning in this study.
1. Optimization structures included were the Opti Bowel Bag and Opti
Bladder structures.
1. The Opti Bowel Bag structure was created by cropping the bowel bag
normal structure from going into the PTV, with a 0.1 cm margin.
2. Similarly, the Opti Bladder structure was created by cropping the bladder
normal structure from going into the PTV, with a 0.1 cm margin.
D. All treatment plans were optimized to the set prescription dose and referenced set
OAR constraints.
1. All plans were normalized to the PTV target volume so that 95% of the
PTV received 100% of the prescription dose.
2. Single energy plans were optimized to the full prescription dose, while the
two plans used to create the mixed energy plan sum were optimized to
their respective partial prescription doses.
3. Plans were optimized a second time to meet OAR constraints as proposed
by Quantitative Analyses of Normal Tissue Effects in the Clinic
(QUANTEC) and the Radiation Therapy Oncology Group (RTOG). 13
Plan Comparisons
A. The three treatment plan types created for each patient were compared.
1. The three plan types included the 6 MV photon plan with full prescription
dose, the 10 MV photon plan with full prescription dose, and the mixed
energy plan sum created from the 6 MV and 10 MV plans with partial
prescription doses.
2. The comparisons were in terms of OAR sparing, monitor unit (MU) usage,
and PTV coverage
B. The OAR considered in comparing the 6 MV and 10 MV single energy plans with
the mixed energy plans were chosen based on QUANTEC and RTOG standards.
 7

1. The OAR included the bladder, bowel bag, external genitalia or vagina,
and femoral heads.
2. Specific comparison points were included from QUANTEC and RTOG
normal tissue tolerances.
C. The MUs were compared between plan types.
1. The total MUs for each arc of each plan type were totaled and averaged
between patients.
D. The PTV was also compared between plan types in terms of uniformity and
coverage.
1. The PTV coverage was determined using the conformity index.
2. The PTV uniformity was determined using the heterogeneity index.
IV. Results
A. This section should reflect on each patient and the results of the treatment
planning (ex: what the dose to the target was, dose to each OR structure ect.). This
is the section where you pull in your statistical analysis parameters
V. Discussion
A. This is the section that draws your independent research together with your
literature review to discuss your results and if they make sense. Questions you
should answer while writing your discussion: What do you conclude based on the
results of your study? Is this consistent with the literature you found? If not, why
do think that is?
VI. Conclusion
A. Should be a short summary of your paper and answer these questions: Are there
limitations to your study such as sample size, varying clinical sites ect.? What
further research should be done on your topic? You should include citations to
support you research findings
 8

References

1. Mattes MD, Tai C, Lee A, et al. The dosimetric effects of photon energy on the quality of
prostate volumetric modulated arc therapy. Pract Radiat Oncol. 2014;4(1):e39-44.
https://doi.org/10.1016/j.prro.2013.03.001.
2. Gurjar O, Jha V, Sharma S. Radiation dose to radiotherapy technologists due to induced
activity in high energy medical electron linear accelerators. Radiation Protection and
Environment. 2014;37(1):25. https://doi.org/10.4103/0972-0464.146460.
3. Yadav G, Kumar L, Raman K, et al. The dosimetric impact of different photon beam
energy on RapidArc radiotherapy planning for cervix carcinoma. J Med Phys.
2015;40(4):207. https://doi.org/10.4103/0971-6203.170787.
4. Vuong T, Devic S, Belliveau P et al,. Contribution of conformal therapy in the treatment
of anal canal carcinoma with combined chemotherapy and radiotherapy: results of a
Phase II study. Int J Rad Onc Bio Phys. 2003;56(3):823-831. https://doi:10.1016/s0360-
3016(03)00016-6.
5. Chuong M, Freilich J, Hoffe S, et al. Intensity-modulated radiation therapy versus 3D
conformal radiation therapy for squamous cell carcinoma of the anal canal. J Clin Oncol.
2013;31(4_suppl):494-494. https://doi:10.1200/jco.2013.31.4_suppl.494.
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. https://doi:10.1186/1748-717x-5-92.
7. Clivio A, Fogliata A, Franzetti-Pellanda A, et al. Volumetric-modulated arc radiotherapy
for carcinomas of the anal canal: A treatment planning comparison with fixed field
IMRT. Radiother Oncol. 2009;92(1):118-124. https://doi:10.1016/j.radonc.2008.12.020.
8. Franco P, Arcadipane F, Ragona R, et al. Volumetric modulated arc therapy (VMAT) in
the combined modality treatment of anal cancer patients. Brit J Radiol.
2016;89(1060):20150832. https://doi:10.1259/bjr.20150832.
9. Park JM, Choi CH, Ha SW, et al. The dosimetric effect of mixed‐energy IMRT plans for
prostate cancer. J App Clin Med Phys. 2011;12:147-157.
https://doi.org/10.1120/jacmp.v12i4.3563
 9

10. Momin S, Gräfe JL, Khan RF. Evaluation of mixed energy partial arcs for volumetric
modulated arc therapy for prostate cancer. J Appl Clin Med Phys. 2019;20(4):51-65.
https://doi.org/10.1002/acm2.12561.
11. Pokharel S. Dosimetric impact of mixed‐energy volumetric modulated arc therapy plans
for high‐risk prostate cancer. Int J Cancer Ther Oncol. 2013;1:1.
http://doi.org/10.14319/ijcto.0101.1.
12. Mcgeachy P, Villarreal-Barajas JE, Zinchenko Y, et al. Modulated photon radiotherapy
(XMRT): an algorithm for the simultaneous optimization of photon beamlet energy and
intensity in external beam radiotherapy (EBRT) planning. Phys Med Biol.
2016;61(4):1476-1498. https://doi.org/10.1088/0031-9155/61/4/1476.
13. Marks LB, Yorke ED, Jackson A, et al. Use of Normal Tissue Complication Probability
Models in the Clinic. Int J Radiat Oncol Biol Phys. 2010;76(3):S10-S19.
http://dx.doi.org/10.1016/j.ijrobp.2009.07.1754.