1

Reducing Mean Heart Dose with Partial Arc Volumetric Modulated Arc Therapy for Left-
Sided Lung Tumors Treated with Stereotactic Body Radiation Therapy
Alex Mckennell BS R.T.(T); Martina Stewart BS R.T.(T); Melissa Piercey BS R.T.(T);
Nishele Lenards, PhD, CMD, RT(R)(T), FAAMD; Ashley Hunzeker, MS, CMD; Matt Tobler,
R.T.(T), CMD, FAAMD
University of Wisconsin-La Crosse Medical Dosimetry Program
I. Abstract
A. PI: Summarize study
i. Problem
ii. Purpose
iii. Number of patients chosen for retrospective study
iv. Type of plans created for analysis
v. OAR evaluation
vi. Statistical tests used
vii. Results
viii. Null hypothesis rejection statement
II. Introduction
A. PI: Lung Cancer Fact Sheet (References: American Cancer Society,1 World
Health Organization2)
B. PII: The need to reduce mean dose to the heart during lung irradiation
(References: Atkins et al,3 Banfill et al,4 Kearney et al,5 Afrin et al6)
i. RTOG 0617 and QUANTEC
C. PIII: The use of Volumetric Modulated Arc Therapy (VMAT) for treating lung
cancer (References: Afrin et al,6 Ko et al,7 Weiz et al,8 Hunte et al9)
D. PIV: Determining appropriate beam arrangement (Hunte et al,9 Kim et al10)
i. Coplanar vs. non coplanar
E. PV: Summarize introduction points
a. Problem: When treating tumors in the left lung near the heart, the
heart can receive mean doses > 40 Gy and can increase the
potential for cardiac toxicity.
 2

b. Purpose: The purpose of this research study was to evaluate

Volumetric Modulated Arc Therapy (VMAT) configurations for
left sided lung tumors near the heart to determine a technique that
will deliver a mean heart dose of < 40 Gy while maintaining 95%
PTV coverage.
c. Hypothesis: Therefore, researchers tested the hypothesis that using
two partial VMAT arcs compared to two full VMAT arcs for left-
sided lung tumors will reduce the mean dose to the heart to < 40
Gy while still maintaining 95% planned tumor volume (PTV)
coverage.
III. Materials and Methods
A. Patient Selection and Setup
a. PI: Patient population
a. 20 patients
b. 17 patients utilized breath hold and 3 patients utilized free
breathing
b. PII:
a. Inclusion criteria (left sided lung tumors that are in level
with the heart, treated at Michigan Medicine and Brighton
Center for Specialty Care. 50 Gy in 5 fractions)
b. Exclusion criteria (right sided tumors, mediastinal tumors,
no boosts, no lymph nodes)
c. PIII: Simulation and equipment set-up image (Figure 1)
a. Thorax board, arms above head in cup holders, knee fix,
head rest
b. Daily Cone Beam CT imaging (CBCT)
B. Contours
a. PI: Targets
a. Breath-hold
i. CT scan completed
ii. Physician draws gross tumor volume (GTV)
 3

iii. Certified medical dosimetrist adds a 0.5 cm to 0.8

cm margin around GTV to create the PTV.
b. Free breathing
i. 4DCT scan completed
ii. Physician draws GTV on each phase of 4DCT
iii. Physicist creates IGTV based off 4D average
iv. Certified medical dosimetrist adds a 0.5 cm to 0.8
cm margin around IGTV to create PTV
b. PII: OAR
a. Heart and left lung (Reference Banfill et al,3 Kearney et
al,4)
C. Planning Details
a. PI: Isocenter location and plan parameters
a. Iso placed in center of PTV
b. 10 Gy x 5 fractions to a total dose of 50 Gy
c. 6 FFF energy used
d. Dose rate 1400
e. Full arcs: CW 181-179, collimator 30-degrees; CCW 179-
181, collimator 330-degrees
f. Half arcs: CW 10-170, collimator 30-degrees; CCW 170-
10, collimator 330-degrees
b. PII-IV: Planning procedure
c. PII: Place iso and set up beam and collimator arrangements
d. PIII: Create optimization structures and dose objectives
e. PIV: Run optimization and evaluate
D. Plan Comparison
a. PI: Evaluating metrics
a. OAR: Mean heart dose
b. Target: PTV (95% of volume receiving 100% of the dose)
E. Statistical Analysis
a. T-test
 4

a. One-tailed t-test
b. P < 0.05 is considered statistically significant
IV. Results
A. PI: PTV coverage results
a. D95 PTV without heart avoidance
b. D95 PTV with heart avoidance
B. PII: OAR results
a. Mean heart dose without heart avoidance (Figure 2) (Table 1)
b. Mean heart dose with heart avoidance P < 0.05 (Statistically
significant) (Figure 2) (Table 1)
C. PIII: Reject or fail to reject the null hypothesis
a. Mean heart dose with avoidance < 40 Gy = reject the null
hypothesis
V. Discussion
A. PI: Summarize PTV coverage results in relation to heart avoidance and without
heart avoidance
a. No significant difference in PTV coverage without heart avoidance
and with heart avoidance
B. Summarize mean heart dose in relation to heart avoidance and without heart
avoidance
a. Reference Figure 2 and Table 1
C. PIV: Summarize all results in study to recap
a. Relate results to conclusion of Atkins et al,3 importance of
avoiding excess cardiac dose
b. Importance of VMAT arc configurations to avoid treating through
the heart (Reference Atkins et al,3)
VI. Conclusion
A. PI-PII: Summarize the study
a. Problem: When treating tumors in the left lung near the heart, the
heart can receive mean doses > 40 Gy and can increase the
potential for cardiac toxicity.
 5

b. Purpose: To evaluate VMAT arc configurations for left sided lung

tumors near the heart to determine a technique that will deliver a
mean heart dose of < 40 Gy while maintaining 95% PTV coverage.
B. PIII: Limitations/future research
a. Limitations
a. All patients were collected from 1 institution with the same
TPS, machine and algorithm
b. Only 20 patients were studied
b. Future research
a. Different TPS and treatment machine
b. Apply this study to non-centrally located left lung tumors
c. Larger patient sample size
Acknowledgements
The authors would like to thank Dr. Douglas Baumann of the Statistical Consulting
Center at the University of Wisconsin – La Crosse for assistance with analysis and interpretation
of statistical data; any errors of fact or interpretation remain the sole responsibility of the authors.

References
 6

1. American Cancer Society. Lung Cancer Fact Sheet: https://www.lung.org/lung-health-

diseases/lung-disease-lookup/lung-cancer/resource-library/lung-cancer-fact-sheet Updated
November 17, 2022. Accessed March 24, 2023.
2. World Health Organization. WHO Reveals Leading Causes of Death and Disability
Worldwide: 2000-2019: https://www.who.int/news/item/09-12-2020-who-reveals-leading-
causes-of-death-and-disability-worldwide-2000-2019 Updated December 9,2020. Accessed
March 23, 2023.
3. Atkins KM, Rawal B, Chaunzwa TL, et al. Cardiac radiation dose, cardiac disease, and
mortality in patients with lung cancer. J Am Coll Cardiol. 2019;73(23):2976-2987.
http://doi.org/10.1016/j.jacc.2019.03.500.
4. Banfill K, Giuliani M, Aznar M, et al. Cardiac toxicity of thoracic radiotherapy: existing
evidence and future directions. J Thorac Oncol. 2021;16(2):216-227.
http://doi.org/10.1016/j.jtho.2020.11.002.
5. Kearney M, Keys M, Faivre-Finn C, Wang Z, Aznar MC, Duane F. Exposure of the heart in
lung cancer radiation therapy: a systematic review of heart doses published during 2013 to
2020. Radiother Oncol. 2022;172:118-125. http://doi.org/10.1016/j.radonc.2022.05.007.
6. Afrin KT, Ahmad S. Is imrt or vmat superior or inferior to 3D conformal therapy in the
treatment of lung cancer? A brief literature review. J Radiother Pract. 2022;21(3):416-420.
http://doi.org/10.1017/S146039692100008X.
7. Ko YE, Ahn SD, Je HU. Usability and necessity of a novel hybrid radiation therapy
technique based on volumetric modulated arc therapy (VMAT) in stage III lung cancer
treatment. Radiat Phys Chem Oxf Engl. 2022; 195:110054.
http://doi.org/10.1016/j.radphyschem.2022.110054.
8. Wei Z, Peng X, He L, Wang J, Liu Z, Xiao J. Treatment plan comparison of volumetric-
modulated arc therapy to intensity-modulated radiotherapy in lung stereotactic body
radiotherapy using either 6- or 10-MV photon energies. J Appl Clin Med Phys.
2022;23(8):e13714. http://doi.org/10.1002/acm2.13714.
9. Hunte SO, Clark CH, Zyuzikov N, Nisbet A. Volumetric modulated arc therapy (VMAT): a
review of clinical outcomes-what is the clinical evidence for the most effective
implementation? Br J Radiol. 2022;95(1136):20201289.
http://doi.org/10.1259/bjr.20201289.
 7

10. Kim ST, An HJ, Kim JI, Yoo JR, Kim HJ, Park JM. Non-coplanar VMAT plans for lung
SABR to reduce dose to the heart: a planning study. Br J Radiol. 2020;93(1105):20190596.
http://doi.org/10.1259/bjr.20190596.

Figures
 8

Figure 1. Patient immobilization devices utilized in CT simulation and daily treatment set-up.
 9

Figure 2. Comparison of mean heart dose with and without heart avoidance.
 10

Tables
Table 1. Mean heart dose with and without heart avoidance by patient.
Mean Heart Dose with Mean Heart Dose without Difference in Mean Heart
Patient Avoidance (Gy) Avoidance (Gy) Dose (Gy)
1 1.253 1.398 0.145
2 3.558 4.588 1.03
3 4.643 4.771 0.128
4 1.687 2.158 0.471
5 1.494 1.641 0.147
6 0.242 0.244 0.002
7 1.894 2.335 0.441
8 8.248 8.656 0.408
9 2.627 3.003 0.376
10 1.836 2.028 0.192
11 3.431 3.825 0.394
12 2.332 2.76 0.428
13 1.834 2.099 0.265
14 0.156 0.149 -0.007
15 5.598 5.642 0.044
16 3.913 4.455 0.542
17 1.769 2.006 0.237
18 3.606 3.773 0.167
19 1.28 1.554 0.274
20 4.963 5.329 0.366
Gy = Gray