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Dosimetric comparisons for jaw tracking optimization versus static jaw technique using
VMAT for thorax irradiation.
Dewey Wright R.T. (R)(T)(CT), Reisha Willis R.T. (T)
ABSTRACT
Radiotherapy treatment of the lung using volumetric modulated arc therapy (VMAT) has been
proven to be beneficial for sparing of critical structure tissues while allowing a conformal dose
distribution for target tumor volume coverage. Low dose radiation to the normal lung tissue can
result in possible radiotherapy toxicities as well as secondary malignancies. Although VMATs
improvements have shown in lowering dose surrounding tumor volumes, the low dose
contribution is still significant. The tongue and groove effect has been shown to increase dose to
tissues surrounding target volumes. The focus of this study is to investigate the advantages of
using jaw tracking in VMAT involving lung cancer patients to attempt to lower the lower dose to
the normal lung tissue. Goals concerning critical structure sparing while maintaining optimal
tumor coverage were evaluated. The V5 of lung volume has been of concern as the National
Comprehensive Cancer Network (NCCN) guidelines have suggested a dose of 65Gy. The
VMAT technique while effective still gives higher V5 lung dose than specified by the NCCN. In
this study fifteen new patients and previously treated patients were randomly selected with
moderate to high-risk lung cancer. The NCCN guidelines were used for target and organ at risk
(OR) structure contouring. The techniques that were utilized were VMAT using 2 partial arcs to
avoid entry into contralateral lung. The prescribed dose for each plan consisted of 70 Gy in 2 Gy
daily fractions to the planned tumor volume (PTV). The goal of this study is to evaluate the dose
to the OR structures while delivering 95% of the prescribed dose to the PTV while utilizing jaw
tracking capabilities versus without the jaw tracking optimization enabled. A total of 30 plans
were constructed 2 plans per patient one with jaw tracking optimization enabled with the other
having a static jaw. Evaluations were made using the conformity index (CI), the monitor units
(MU) given, OR structure doses received, and the normal tissue integral dose (NTID).
Key words: VMAT, jaw tracking, lung cancer
Introduction

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Lung cancer is the leading cause of cancer deaths for both men and women. Depending
on stage, involvement, and location of tumor volumes radiation therapy, surgery, chemo,
adjuvant or any combination of treatment may be an option. With external beam radiation
therapy (EBRT), normal surrounding tissues are of concern as secondary malignancies can be
introduced as well as toxicity during treatment.1 Mediastinal involvement can prove to be
challenging delivering dose to the targeted tumor mass and sparing normal surrounding lung
tissue. Advancements in radiotherapy techniques are improving the risks of neighboring normal
tissues and OR volumes.
The standard EBRT treatment for lung cancer was a three-dimensional conformal therapy
(3DCRT) technique utilizing static multileaf collimator (MLC) patterns and field-shrinking
target boosts with beam geometry changes to achieve the prescribed target volume dose
coverage. Studies have suggested increased radiation tumor dose can improve tumor control
however with 3DCRT the field sizes are usually large thus compromising higher tumor dose
possibilities due to neighboring OR volumes.2 Evolving technology allowed for advancement in
techniques. Intensity modulated radiation therapy (IMRT) allows for a dynamic translation of
MLC leaves at various speeds during each arranged field irradiation the upper and lower static
jaws allowed for a more conformal dose to the targeted treatment volume while sparing
neighboring OR structures. One drawback of IMRT was the tongue and groove effect of
transmitted dose through MLCs that could increase with increased field size.3
The VMAT technique improved upon static IMRT with the addition of rotational
dynamic arcing IMRT fields resulting in less beam time with increased normal tissue sparing.
Quan et al4 demonstrated 17% and 14% higher PTV dose conformality, 8% and 17% lower mean
lung dose, 17% and 26% lower mean heart dose, and 36% and 23% higher tumor control
probability could be obtained with VMAT in stage III lung cancer treatment. Kataria et al5 found
that the mean lung dose (MLD) was reduced using VMAT when treating thorax tumor volumes
centrally located with esophageal cancers. Although the advantages of VMAT versus IMRT are
clear, there are still issues of MLC leakage as with that found in IMRT treatment. The MLC
leakage brought on by the tongue and groove effect could be a valid contributor to the lower lung
dose, which can be predictors for radio pneumonitis. Plans using the VMAT technique for tumor

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volumes centrally located have shown improvements for total lung dose, MLD and V20 have
been improved the V5 lung dose still remains at higher than NCCN guideline levels.
An optimization technique using a dynamic jaw tracking or following the dynamic
movement of the MLCs might be beneficial in blocking the leakage produced by the tongue and
groove effect produced by the sliding MLC fields. The dosimetric benefits of using jaw tracking
with IMRT head and neck as well as prostate treatments have been shown to reduce unwanted
dose leakage.6,7 Varians TrueBeam technology along with proprietary treatment planning
software allows for a method in which the jaws can introduce a dynamic movement tracking and
following of the dynamic MLC pattern coupled with the rotational arc of the gantry when used
with the VMAT technique. The benefits of both the VMAT technique and jaw tracking
optimization for the prostate and head and neck showed a significant decrease in mean dose to
OR structures while conforming the dose to the target volume.8 The jaw tracking optimization
has shown to be a potential benefit when using VMAT in the treatment of stereotactic spine
cases as well. Snyder et al9 concluded that dose to the normal tissue of the spinal cord could be
reduced without affecting target volume coverage and accuracy. A comprehensive study was
performed by Feng et al10 assessing the potential advantages for jaw tracking in regards to
sparing of OR structures in a total of 28 patients in several areas of the body including the head
and neck, lungs, esophageal, abdominal, prostate, rectal, and cervical areas. The findings showed
an improvement in OR sparing and normal tissue lung sparing with jaw tracking and IMRT
however did not evaluate the optimization with VMAT techniques.
The purpose of this paper was to perform an in depth look at using the jaw tracking
optimization with the VMAT technique in lung patients with a concentration on lowering the V5
total dose to the normal lung tissue volume.
Methods and Materials
Patients
Fifteen patients were randomly selected with the criteria of having primary lung
adenopathy in the thorax region. All patients were simulated in the supine position utilizing a
General Electric - CT scanner with 2.5 mm slices. Vac-Lok immobilization devices were used in
conjunction with Civco wingboards to immobilize patients in the treatment position. The

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patients arms were positioned in an upward position with hands above the head holding the T
bar to facilitate no involvement in the treatment field beams. Marks were placed at isocenter on
each patient using the LAP laser isocenter computer guided laser system. With the use of image
guided radiation therapy techniques (IGRT) the reproducibility was ensured for each patients
treatment setup. The IGRT technique with on board imaging (OBI) equipment has been shown to
effectively allow greater reproducibility of dose delivery to the target tumor volume through
verification of anatomical structure geometry.11 Using weekly 4D-cone beam computed
tomography (4D-CBCT) and daily kV to kV imaging the geometry between the planned patient
setup and actual treatment setup was performed by the radiation therapists.
Contouring
Using Varian Eclipse treatment planning system (TPS) version 11.0, target volumes were
identified and delineated by the radiation oncologist and patient OR were delineated and
contoured, following the Radiation Therapy Oncology Group (RTOG) contouring atlases along
with the NCCN guidelines for target and OR volumes. The PTV included the clinical treatment
volume (CTV) and the gross tumor volume (GTV), both delineated by the oncologist, with an
additional 0.5 cm margin. The OR structures for all patients included the lung, heart, spinal cord,
esophagus, liver, and brachial plexus all of which were contoured as solid organs.
Treatment Planning
The prescribed dose for each lung patient was 70 Gy delivered in 2 Gy per day with a
total of 35 fractions. All plans were created separately for treatment using a Varian TrueBeam
linear accelerator equipped with a Millennium 120-leaf multileaf collimator using 6 and 10 MV
energies. The VMAT plans for the lung consisted of 2 partial arcs. The collimator angles ranged
from 15-30 degrees with and without jaw tracking optimization enabled. A total of 30 plans were
constructed, with 2 plans per patient to evaluate the jaw tracking benefits. Beam geometrical
parameters are demonstrated (Table 1) All plans were planned with isocenter placed with in
geometrical center of the CTV. The plans were optimized to meet the NCCN guidelines for OR
constraints. The plans were also optimized to deliver a minimum 95% of the prescribed dose to
100% of the PTV.

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Plan comparisons
Plan comparisons were performed analyzing the dose CI, dose volume histograms
(DVH), MUs, OR doses, and NTID. Isodose distributions were analyzed demonstrated (Figure
1). The DVHs of each GTV, CTV, and PTV along with OR are demonstrated (Figure 2). The CI
of the PTV for both sets of plans were evaluated and are demonstrated (Figure 3). The MU
differences were evaluated between both plans with an overall percentage difference calculated
and shown in (table 2)
Results
To be determined
Discussion
To be discussed after results
Conclusion
To be made after results...

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Tables

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Figures