1

Minimizing dose to the heart, left anterior descending artery, and lungs in whole breast
irradiation by reducing interleaf transmission on Elekta linear accelerators
Shelby Hall, BS, R.T.(T); Makelle Barski, BS, R.T.(T); Madeline Doberstein, BS, R.T.(T);
Nishele Lenards, PhD, CMD, R.T.(R)(T), FAAMD; Ashley Hunzeker, MS, CMD; Alyssa Olson,
MS, R.T.(T), CMD; Thomas J. Quinn, MD
Medical Dosimetry Program at the University of Wisconsin-La Crosse, WI
ABSTRACT
The most frequently used collimator angles in breast treatments could yield more interleaf
leakage when using an Elekta linear accelerator. The purpose of this retrospective study was to
determine if an additional collimator rotation of 90°, in standard right and left whole breast
irradiation, would reduce the interleaf transmission and dose to critical structures while
maintaining adequate coverage of the planning target volume (PTV). Sixty-five patients were
selected for this study and were planned using an inverse-planned 3D conformal technique. Plans
were compared with and without the additional collimator rotation by evaluating target volume
coverage and dose to critical structures. Dosimetric data was evaluated for normality, and
medians were compared using the Wilcoxon Signed Rank test. Effect size was evaluated per
Cohen’s classification. All statistical analyses were performed using RStudio. A collimator
rotation resulted in a statistically significant reduction in the median dose maximum (Dmax) (5.2
vs. 4.6 Gy, P < 0.001) and mean heart (0.83 vs. 0.62 Gy, P < 0.001) dose. Likewise, there was a
statistically significant reduction in the mean left anterior descending artery (LAD) dose (2.7 Gy
vs. 2.4 Gy, P < 0.001). Additionally, the collimator rotation resulted in a statistically significant
reduction in the mean lung (4.4 vs 4.2 Gy, P < 0.001) dose, without affecting the volume of PTV
receiving 100% prescription dose (88.7 vs. 88.2%, P = 0.834). The additional collimator rotation
is an effective method to reduce interleaf transmission and should be considered for breast
treatment planning on Elekta linear accelerators.

Keywords: Radiotherapy, Cardiotoxicity, Cohort Analysis, Interleaf Transmission, Breast

Irradiation, Elekta Linear Accelerator
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Introduction
The goal of radiation therapy treatment is to provide adequate coverage to the tumor
while sparing the surrounding normal tissue. In tangential breast treatment, dose to the heart,
lungs, and other critical structures can cause serious side effects such as ischemic heart disease,
congestive heart failure, and radiation pneumonitis.1 The heart has a recommended mean dose
limit of 5 Gy; however, there is still a risk for a major coronary event below this dose.2
According to Darby et al,3 the risk of a major coronary event increases linearly as the mean heart
dose increases and does not show any threshold below which there is no risk. Specifically, it was
found that for each Gy the heart receives, the risk for ischemic heart disease increases on average
by 7.4%. To reduce the risk of ischemic heart disease, many techniques have been developed that
reduce dose to critical structures in breast treatments, such as intensity-modulated radiation
therapy (IMRT), prone breast radiotherapy, deep inspiration breath-hold (DIBH), partial breast
irradiation, and proton beam therapy.4 In a systematic meta-analysis of studies (2003-2013) on
mean heart dose for the treatment of left-sided breast cancer, it was shown that the supine
position, with no breath-hold, was the most common position for treatment.5 While the
techniques listed above are certainly advantageous to the patient, the heart can still receive 1 to 5
Gy in these treatments.3,4
A collimator angle of 0° is frequently used in tangential breast treatments. If collimator
rotations are utilized, the collimator is often rotated parallel to the chest wall to help limit dose to
the lung. However, these commonly used angles could be yielding more interleaf transmission
than necessary when using an Elekta linear accelerator. The collimation design of an Elekta
linear accelerator is that of a single set of diaphragms that move perpendicular to the multi-leaf
collimator (MLC).6 A study regarding interleaf leakage on an Elekta Synergy machine showed
that there was an average interleaf leakage of 1.9% for a 6 MV photon beam.7 Chen et al8
compared doses to critical structures in IMRT lung cases with various MLC transmission values;
the lowest transmission value showed a decrease in lung dose, which could reduce the chances
for radiation pneumonitis. In a similar study by Chapek et al,9 dose to the rectal wall in prostate
treatment plans was shown to decrease with an optimal collimator angle meant to minimize
transmission through MLC leaves. On the contrary, Sharma et al10 found no difference in dose
transmission regardless of collimator angle when researching parotid gland irradiation and dose
to the contralateral parotid gland and cochleae.
 3

In an exhaustive literature review, the researchers were unable to locate similar studies
using an optimal collimator angle to reduce MLC interleaf transmission and limit dose to critical
structures in breast cancer treatment. While many strategies have been developed to reduce dose
to critical structures, there continues to be a need for simple techniques that can adequately
address minimizing dose to organs at risk (OAR) while maintaining target coverage. Therefore,
the relationship between interleaf transmission dose to critical structures (heart, left anterior
descending artery (LAD), and lung) and collimator rotation during whole breast irradiation needs
to be evaluated. The purpose of this retrospective study was to determine if an additional
collimator rotation of 90°, in standard right and left whole breast irradiation, would reduce the
interleaf transmission and dose to OAR while maintaining adequate coverage of the target
volume. Therefore, researchers tested the hypotheses that there was no relationship between
interleaf transmission and dose to the heart (H10), LAD (H20), lung (H30-H60), and evaluated
planning target volume (PTV_Eval) (H70). All statistical analyses were performed using 2-sided
testing with P < 0.05 considered statistically significant.

Methods and Materials

Patient Selection & Setup
Sixty-five patients from a single institution were chosen for this study. The inclusion
criteria were female patients with stage 0, I, or II breast cancer, treated using tangential fields in
the supine position. Patients with lymph node involvement were excluded from this study. The
patient data was collected retrospectively to include 35 patients with left-sided breast cancer and
30 patients with right-sided breast cancer. Of the patients selected, 15 patients had stage 0 ductal
carcinoma in situ (DCIS), 44 patients had invasive ductal carcinoma (IDC) stages IA-IIB, and 6
patients had invasive lobular carcinoma (ILC) stages IA-IB. All patients were prescribed a dose
of 42.56 Gy in 16 fractions with a curative intent. Any dose from a boost was not considered in
the final plan comparison due to variations in boost planning methods used at the institution.
Each patient was simulated using a Philips CT scanner. The patients were positioned
head-first supine with both arms above the head (Figure 1). An upper body alpha cradle was
created to reproduce the arm position daily. Radio-opaque markers were placed at the superior,
inferior, medial and lateral borders of the treatment area by the physician. Thirty patients were
simulated using a DIBH technique, and 35 patients were simulated free-breathing. Each scan was
obtained using a 3 mm slice thickness from the inferior aspect of the mandible superiorly to 5 cm
 4

below the breast tissue inferiorly. The scan was then exported to the Pinnacle (Version 14.0)
treatment planning system (TPS).
Contours
The CT scan obtained and imported from CT simulation was used for the contouring of
OAR and target volume delineation. The clinical target volume of the surgical bed (CTVsb) was
contoured manually by the physician. According to department protocols, the planning target
volumes (PTVs) were defined using the tangential fields (further discussed in treatment
planning). Coplanar tangent treatment fields were placed by the physician and a breast contour
was created from the 50% isodose line (avoiding exterior of the body contour and the lung). The
breast contour was contracted 5 mm to create the PTV_Eval.
The OAR contoured in this study were the heart, left lung, right lung, and LAD. Both
lungs were contoured using an auto-contouring tool in a pulmonary window level following the
Radiation Therapy Oncology Group (RTOG) 1106 contouring atlas.11 The heart was contoured
manually by the physician or medical dosimetrist following the RTOG 1106 contouring atlas.
Lastly, the LAD was contoured manually by the physician or medical dosimetrist.
Treatment Planning
All 65 patients were planned by using an inverse-planned 3D conformal technique in the
Pinnacle TPS as described by Van Asselen.12 Dose calculations were performed using the
Collapsed Cone Convolution (CCC) algorithm. Pinnacle’s direct machine parameter
optimization (DMPO) was used to generate segmented fields. A combination of 6 MV, 10 MV,
and 18 MV were used depending on patient size and ability to meet planning objectives. All
patients were planned for treatment on an Elekta Synergy or Elekta Agility linear accelerator.
Both medial and lateral tangent fields were established by the physician. Open fields,
labeled “OpenMed” and “OpenLat,” were designed by the physician utilizing the superior and
inferior borders defined during simulation. The gantry angles varied but were designed to
encompass the entire breast, avoid entrance and exit dose to the contralateral breast, and limit the
amount of lung included. Beam edges were adjusted to be nondivergent medially. Based on the
physician's preference, MLC leaves may have been added and shaped by the physician for
additional cardiac shielding. Open fields included 2 cm of flash on the breast tissue anteriorly.
The collimator angle for each field remained at 0 or was rotated such that the collimator jaw
 5

edge was parallel to the ipsilateral lung cavity to further decrease dose to the OAR (Figure 2A).
Additionally, a couch rotation was used to reduce dose to the underarm when necessary.
To obtain segmented fields, the medial and lateral fields and any corresponding MLCs
were copied and labeled “SegMed” and "SegLat.” Before optimization, the IMRT parameters for
OpenMed and OpenLat were set to “beam weight.” The beam weight setting in Pinnacle finds
the optimal weight between the 2 open fields. The IMRT parameters for SegMed and SegLat
were set to DMPO. Thus, during inverse optimization, the shape of the OpenMed and OpenLat
fields remained fixed as the weighting of each field was optimized. Simultaneously, the SegMed
and SegLat fields were optimized to create and weight segmented fields. After optimization was
complete, the open fields were appropriately weighted and segments were created to decrease
hotspots for a homogeneous dose distribution. Plans were optimized until the objectives were
met using the dose constraints provided by the Michigan Radiation Oncology Quality
Consortium (MROQC) breast study.13
Once the planning objectives were met, the plan was copied into a new trial. On the new
trial, the collimator on the OpenMed and OpenLat were rotated an additional 90° to allow the
MLC leaves to run vertically (Figure 2B). Furthermore, if a heart block was drawn, it was
recapitulated following collimator rotation. The collimator angle for the segmented fields
remained at the original position. These fields were re-calculated and the doses to the OAR and
planning volumes were recorded for both trials.
Plan Comparison
The PTV_Eval and OAR were compared between the 2 trials: no additional collimator
rotation and the additional 90° collimator rotation. The mean dose to the heart was analyzed
using dose constraints based on the MROQC study. These constraints included a mean dose to
the heart of 1.2 Gy on a left-sided breast plan, or 0.7 Gy on a right-sided breast plan. Other
analyzed metrics included the maximum dose (Dmax) to the heart, and, for left-sided breast
patients only, the LAD mean and LAD Dmax doses. The ipsilateral lung dose was analyzed using
the volume receiving 20 Gy (V20), volume receiving 10 Gy (V10), and volume receiving 5 Gy
(V5) values. Finally, the PTV_Eval coverage was analyzed by the percent volume of PTV_Eval
that received 90% of the prescription dose (V90), the percent volume that received 95% of the
prescription dose (V95), and the percent volume that received 100% of the prescription dose
 6

(V100). This information was then used to derive mean values and mean percent differences from
the data collected.
Statistical Analysis
Each plan was evaluated individually to collect data for this study. Prior to analysis, the
data was evaluated for normality graphically and statistically using Q-Q plots and the Shapiro-
Wilk test, respectively. The dosimetric data evaluated did not have a Gaussian distribution;
therefore, the non-parametric related samples Wilcoxon Signed Rank test (WSR) was used to
compare whether the median difference between the related samples was different from 0. The
WSR was performed on the following critical structure dosimetry: mean heart dose, heart Dmax,
mean LAD dose, LAD Dmax, mean lung dose, lung V20, lung V10, and lung V5. Likewise, the
WSR was performed for the PTV_Eval coverage, defined as the percent volume receiving the
following doses: V100, V95, and V90. The effect size (r) of the collimator rotation was calculated
|𝑍|
as 𝑟 = , where Z is the standardized Z statistic and N is the number of pairs.14 Overall effect
√𝑁

size was evaluated per Cohen’s15 classification: < 0.2 (small), 0.2-0.8 (medium), > 0.8 (large).
All statistical analyses were performed using RStudio (v1.2.1335) and SPSS (v24, IBM). In
addition, all statistical analyses were performed using 2-sided testing with P < 0.05 considered
statistically significant. The following R packages were used: ggpubr and ggplot2. R markdown
for all analyses are available upon request.
Results
Collimator Rotation and Heart Dose
To investigate the relationship between collimator rotation and critical structure dose, a
non-parametric related samples WSR test was performed. The median value of the mean heart
dose utilizing the initial collimator angle was 0.83 Gy. When the collimator was rotated an
additional 90°, the median value of the mean heart dose was reduced to 0.62 Gy, corresponding
to a median percent reduction of 25.3%. Similarly, the median heart Dmax among patients with
no collimator rotation was 5.2 Gy and 4.6 Gy with collimator rotation, corresponding to a
median percent reduction of 11.5%. The non-parametric related samples WSR test revealed
statistically significant differences for mean heart (Figure 3A) and Dmax (Figure 3B) doses (P <
0.001), with a large and medium effect size, respectively (Table 1). The null hypothesis (H10)
was that there was no relationship between interleaf transmission and dose to the heart. However,
 7

there was a significant correlation between collimator rotation and heart dose, and the null
hypothesis was rejected.
Collimator Rotation and LAD Dose
For left-sided breast patients in this study (n=35) the median value of the mean LAD dose
was 2.7 Gy before the additional collimator rotation. The mean dose was then reduced to a
median value of 2.4 Gy with a 90° rotation, corresponding to a percent median reduction of
11.1% (Figure 4A). Of note, the median value of the LAD Dmax was 4.7 Gy before the collimator
rotation and increased to 5 Gy after collimator rotation, corresponding to a percent median
increase of 6% (Figure 4B). To investigate the relationship between collimator rotation and heart
dose, a non-parametric related samples WSR test was performed and this revealed that the
majority of plans had reduced mean (34 vs. 1 pair(s), P < 0.001) and Dmax (30 vs. 5 pairs, P <
0.001) LAD doses. This corresponds to a large and medium effect size, respectively (Table 1).
The null hypothesis (H20) was that there was no relationship between interleaf transmission and
dose to the LAD. However, there was a significant correlation between collimator rotation and
LAD dose, and the null hypothesis was rejected.
Collimator Rotation and Lung Dose
The median value of the mean lung dose was 4.4 Gy and 4.2 Gy without and with a
collimator rotation respectively, which corresponded to a percent median reduction of 4.5%
(Figure 5A). Similarly, there was percent median reduction of 2.7%, 5.1%, and 6.1% for the
ipsilateral lung V20, V10, and V5 (Figure 5B-D). As depicted in Table 1, WSR revealed a
statistically significant difference between pairs for mean lung, V10, and V5 (P < 0.001) but not
for V20 (P = 0.164). The null hypothesis (H30) was that there was no relationship between
interleaf transmission and mean lung dose. However, there was a significant correlation between
collimator rotation and mean lung dose, and the null hypothesis was rejected. The null
hypotheses (H40-H50) were that there was no relationship between interleaf transmission and
mean V10 and V5 lung doses. However, there was a significant correlation between collimator
rotation and V10 and V5 lung dose; therefore, the null hypotheses were rejected. Finally, the null
hypothesis (H60) was that there was no relationship between interleaf transmission and V20 lung
dose. There was not a significant correlation between collimator rotation and V20, so the null
hypothesis was accepted.
Collimator Rotation and PTV_Eval Coverage
 8

The PTV_Eval V100 was 88.7% prior to collimator rotation and 88.2% after collimator
rotation, corresponding to a clinically insignificant percent median reduction of 0.56% (Figure
6). Similarly, the PTV_Eval V95 was 99.3% prior to collimator rotation and 99.2% after
collimator rotation (percent median reduction of 0.1%). Finally, the PTV_Eval V90 remained at
100% before and after collimator rotation. The WSR revealed no statistically significant
difference between the paired data for 100% coverage (P = 0.832). However, for V95 coverage,
the number of pairs with reduced coverage, compared to increased coverage, was statistically
significant (36 vs. 23 pairs, P = 0.007). and the number of pairs with reduced coverage,
compared to increased coverage, was statistically significant for V90(26 vs. 10 pairs, P = 0.016).
The null hypothesis (H70) was that there was no relationship between interleaf transmission and
PTV_Eval coverage. However, there was a decrease in coverage for V95 coverage and an
increase in coverage for V90 resulting in rejecting the null hypothesis.
Discussion
The results of the current analysis demonstrated that an additional collimator rotation
would reduce dose to the surrounding OAR. Reducing dose to critical structures should not
compromise dose to target volumes in order to prevent recurrence. Clinically equivalent target
volume coverage was confirmed in this research, which demonstrated that the application of the
additional 90° collimator rotation did not compromise PTV coverage. Additionally, nearly
identical isodose coverage to the PTV_Eval was shown between the 2 trials. The minimal target
coverage difference could occur because interleaf leakage primarily contributes or impacts low
dose levels rather than prescription dose of the target volume (Figure 6). Chapek et al8
demonstrated similar findings in a study of optimal collimator angles to reduce dose to the rectal
wall; comparable coverage to the CTV was shown while dose to the rectal wall was reduced.
Chen et al9 suggested that lower MLC transmission could decrease dose to critical
structures, which was consistent with the findings of the current study. It was also suggested that
lower MLC transmission could be advantageous in lung sparing and reduce the chance of
radiation pneumonitis in cases where there was low or intermediate dose exposure, such as in
breast cancer treatment. Additionally, it was stated that reducing the dose to the lung V5, V20 and
mean lung dose by only a few percent could reduce the risk of radiation pneumonitis.1 While the
Chen et al9 data showed no statistical significance, the current study used a larger sample size
and showed statistical significance for various measured values of lung dose. A reduction in the
 9

lung V5, V10, V20 and mean lung dose was shown between the median values for each plan.
Statistically significant reductions to the mean lung, V10 and V5 doses were shown in the current
study, which confirmed using an additional collimator angle did reduce interleaf transmission.
However, the median V20 doses were not significantly reduced. We suspect that interleaf
transmission contributes predominantly to the lower dose range. Consequently, while the
absolute reduction in dose is likely to be similar, the relative reduction in dose will be lower at
higher dose ranges.
The current study showed a benefit in reducing to dose to the heart. As previously stated,
for every Gy that the mean heart dose is increased, the risk for ischemic heart disease increases
by 7.4%.3 By reducing interleaf transmission with an additional collimator rotation of 90°, the
median mean heart dose was reduced by 25.3%. This reduction was statistically significant
following WSR testing and confirmed that this technique could be utilized to help meet strict
dose constraints, similar to the MROQC breast studies. Finally, reductions to both the Dmax and
mean LAD doses were also shown and could be correlated to the reduction of interleaf
transmission.
Chapek et al8 suggested that using optimal collimator angles, meant to reduce interleaf
transmission, could reduce the dose to surrounding critical structures; the findings of the current
study supported their claim while using a larger sample size. Although the research performed by
Chapek et al8 pertained to prostate treatments, the same concept could be applicable to standard
breast cancer treatment. The current research confirmed that both left and right-sided breast
treatment plans can be improved with minimal changes to the treatment planning process and
workflow with a simple collimator rotation.
Conclusion
The purpose of this retrospective study was to determine if an additional collimator
rotation of 90°, in standard right and left whole breast irradiation, would reduce interleaf
transmission and dose to critical structures while maintaining target coverage. The additional
collimator rotation of 90° was shown to reduce interleaf transmission and dose to critical
structures in standard whole breast irradiation. Therefore, there was a significant correlation
between collimator rotation and dose to OAR. The greatest effects in reducing dose were
observed in the difference of the mean and Dmax heart dose, the mean, V10 and V5 for the lung,
and mean and Dmax dose for the LAD; each of these were found to be statistically significant (P <
 10

0.05). While most OAR displayed a reduction in dose, not all the evaluated dose metrics were
found to be statistically significant, such as the lung V20 (P = 0.164). In addition, adequate
coverage was maintained throughout all plans and any minimal decrease in PTV coverage was
determined to be clinically insignificant.
The limitations of this study included data collection at a single institution using a single
TPS and algorithm. Utilizing multiple institutions could provide an opportunity for a larger
population to determine significance. Additionally, this research could be completed using a
different TPS or linear accelerator for the same anatomical site. Further research may focus on
the specific quadrants of the breast to determine if there is any influence on dose reduction to the
critical structures due to tumor location. Finally, additional research may also be completed to
evaluate if rotating the collimator could reduce dose to critical structures in other anatomical
locations.
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References
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breast cancer treated with hypofractionated radiotherapy following breast-conservative
surgery. J Clin Oncol. 2013;73. https://dx.doi.org/10.1200/jco.2013.31.26_suppl.73
2. Duma MN, Münch S, Oechsner M, Combs SE. Are heart toxicities in breast cancer patients
important for radiation oncologists? A practice pattern survey in German speaking countries.
BMC Cancer. 2017;17(1):563. https://dx.doi.org/10.1186/s12885-017-3548-2
3. Darby SC, Ewertz M, McGale P, et al. Risk of ischemic heart disease in women after
radiotherapy for breast cancer. N Engl J Med. 2013;368(11):987-998.
https://dx.doi.org/10.1056/NEJMoa1209825
4. Taylor CW, Kirby AM. Cardiac side-effects from breast cancer radiotherapy. Clin Oncol.
2015;27(11):621-629. https://dx.doi.org/10.1016/j.clon.2015.06.007
5. Taylor CW, Wang Z, Macaulay E, et al. Exposure of the heart in breast cancer radiation
therapy: A systematic review of heart doses published during 2003 to 2013. Int J Radiat
Oncol Biol Phys. 2015;93(4):845-853. https://dx.doi.org/10.1016/j.ijrobp.2015.07.2292
6. Cosgrove VP, Thomas MDR, Weston SJ, et al. Physical characterization of a new concept
design of an elekta radiation head with integrated 160-leaf multi-leaf collimator. Int J Radiat
Oncol Biol Phys. 2009;75(3):S722-S723. https://dx.doi.org/10.1016/j.ijrobp.2009.07.1646
7. Vikraman S, Janardhan N, Kataria T, et al. Study of interleaf leakage and leaf transmission in
Elekta synergy S beam modulator. Int J Radiat Oncol Biol Phys. 2010;78(3):S756-S757.
https://dx.doi.org/10.1016/j.ijrobp.2010.07.1751
8. Chapek J, Tobler M, Toy BJ, Lee CM, Leavitt DD. Optimization of collimator parameters to
reduce rectal dose in intensity-modulated prostate treatment planning. Med Dosim.
2005;30(4):205-212. https://dx.doi.org/10.1016/j.meddos.2005.06.002
9. Chen J, Fu G, Li M, et al. Evaluation of MLC leaf transmission on IMRT treatment plan
quality of patients with advanced lung cancer. Med Dosim. 2018;43(4):313-318.
https://dx.doi.org/10.1016/j.meddos.2017.10.008
10. Sharma S, Manigandan D, Goyal S, Sahai P. Influence of collimator rotation on dose
distribution and delivery in intensity modulated radiation therapy for parotid cancer. Int J
Cancer Ther Oncol. 2015;3(2):3212. https://dx.doi.org/10.14319/ijcto.0302.12
 12

11. White J, Tai A, Arthur D, et al. Breast cancer atlas for radiation therapy planning: Consensus
definitions. Radiation Therapy Oncology Group (RTOG).
https://www.rtog.org/LinkClick.aspx?fileticket=vzJFhPaBipE= Accessed June 18, 2019.
12. Van Asselen B, Schwarz M, van Vliet-Vroegindeweij C, Lebesque JV, Mijnheer BJ, Damen
EMF. Intensity-modulated radiotherapy of breast cancer using direct aperture optimization.
Radiother Oncol. https://dx.doi.org/10.1016/j.radonc.2006.04.010
13. Pierce LJ, Feng M, Griffith KA, et al. Recent time trends and predictors of heart dose from
breast radiation therapy in a large quality consortium of radiation oncology practices. Int J
Radiat Oncol Biol Phys. 2017;99(5):1154-1161.
https://dx.doi.org/10.1016/j.ijrobp.2017.07.022
14. Rosenthal R. Parametric measures of effect size. In: Cooper H, Hedges LV, ed. The
handbook of research synthesis. 2nd Ed. New York, NY: Russell Sage Foundation; 1993:231.
15. Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. New York:
Psychology Press; 1988.
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Figures

Figure 1. Patient positioned supine with upper body in alpha cradle and arms above
head.

Figure 2. Collimator set at a A) neutral angle (12°) and B) rotated an

additional 90° to 102° so that MLC leaves run parallel to chest wall to reduce
interleaf transmission.
 14

Figure 3. Graphical representation showing the A) mean heart and B) maximum heart dose with
and without 90° collimator rotation.

Figure 4. Graphical representation showing the A) mean LAD and B) maximum LAD dose with
and without 90° collimator rotation.
 15

Figure 5. Graphical representation showing the A) mean lung dose and volume of lung receiving
B) 20 Gy, C) 10 Gy, and D) 5 Gy, with and without 90° collimator rotation.
 16

Figure 6. Dose distribution in the central axis A) before a collimator rotation and B) after an
additional 90° collimator rotation (Green represents 42.56 Gy and yellow represents 44.69 Gy).
 17

Tables

Table 1. Comparison of the median dosimetric data of critical structures between the plans with
no additional collimator rotation (NCR) and the plans with an additional collimator rotation (CR)
using the non-parametric Wilcoxon Signed Ranks test.
Negative Positive Tied Effect
NCR CR P value
Ranks Ranks Ranks Size
Mean (Gy) 0.83 0.62 64 0 1 0.86 < 0.001†
Heart
Dmax (Gy) 5.2 4.6 55 9 1 0.72 < 0.001†
Mean (Gy) 2.7 2.4 34 1 0 0.81 < 0.001†
LAD
Dmax (Gy) 4.7 5 30 5 0 0.73 < 0.001†
Mean (Gy) 4.4 4.2 55 8 2 0.78 < 0.001†

Ipsilateral V20 (%) 7.4 7.2 36 26 3 0.17 0.164†

Lung V10 (%) 11.8 11.2 44 20 1 0.48 < 0.001†
V5 (%) 18 16.9 56 8 1 0.78 < 0.001†
100% 88.7 88.2 32 31 2 0.03 0.834‡
PTV_Eval
95% 99.3 99.2 36 23 6 0.33 0.007†
Coverage
90% 100 100 26 10 29 0.30 0.015†
† Based on positive ranks
‡ Based on negative ranks
Left Anterior Descending Artery (LAD), Planning Target Volume Evaluation (PTV_Eval)