1

Comparison of IMRT and VMAT Techniques for the Reduction of Spinal Cord Dose in
Distal Esophageal Patients: A Case Study
Authors: April Moore B.A., R.T.(R).(T), and Ashley Walsh B.S., CMD, R.T.(T), Nishele
Lenards, M.S., CMD, R.T.(R)(T), FAAMD, Ashley Hunzeker, M.S., CMD
Medical Dosimetry Program at the University of Wisconsin La Crosse, WI
Abstract:
Introduction: This is a retrospective case study comparing intensity modulated radiation therapy
(IMRT) and volumetric modulated arc therapy (VMAT) for patients with distal esophageal
cancer.
Case Description: The purpose of this study was to compare the dose to the spinal cord for each
treatment plan and to discover which plan offered the lowest cord dose while meeting the
treatment planning objectives. Five patients were selected; each patient had an IMRT and VMAT
plan generated for a prescription totaling 50.4 Gy. Dose constraints from the Emami et al1
guidelines were used to ensure dose to organs at risk (OR) were respected as well a target
constraint of 95% of the volume receiving prescription dose was achieved. The Pinnacle and
Eclipse treatment planning software (TPS) were used.
Conclusion: The VMAT and IMRT plans were similar in regards to the planning target volume
(PTV) exposure and OR dose. The spinal cord dose however, was less on the VMAT plans for all
retrospective cases. The total monitor units (MU) and treat times were also considerably different
therefore making VMAT more efficient than IMRT.
Keywords- Spinal Cord dose, IMRT, VMAT, esophageal cancer
Introduction
Esophageal cancer is the second most common solid intra-thoracic tumor next to lung
cancer. There are two main histologic types: squamous cell and adenocarcinoma. A patient with
squamous cell type commonly has disease located in the upper two thirds of the esophagus. Two
of the most common predisposing factors for squamous cell type in the United States are tobacco
usage and heavy alcohol consumption.2A patient with adenocarcinoma usually has disease, such
as Barretts esophagus, located in the distal third near the gastroesophageal junction. Barretts
esophagus occurs when the squamous cell lining of the lower esophagus is replaced by epithelial
lining of the stomach due to long term GERD.2 The primary focus of research to date has been

the heart and lung dose while treating esophageal cancers. Researchers in this retrospective case
study compared two treatment planning techniques, static IMRT to VMAT to evaluate spinal
cord dose as well as the dose to the neighboring organs.
The standard options for treatment of esophageal cancers are surgery alone or
chemotherapy and radiation. The use of all three modalities is currently under clinical
evaluation.3The heart and lung dose have been a major concern in radiation treatment planning
for distal esophageal cancers. It has been shown that reducing the mean lung dose below 20 Gy
as well as keeping the volume of heart receiving 25 Gy (V25) below 10% reduces the risk of
radiation pneumonitis and long term cardiac mortality.3 There have been prior studies that
compare 3-dimensional conformal radiation therapy (3D-CRT), IMRT and VMAT to evaluate
which treatment planning option reduces heart and lung dose the most. These studies showed that
using IMRT can potentially decrease the volume of the lung receiving 10 Gy (V10) by 10%, the
volume of lung receiving 20 Gy (V20) by 5% and a 2.5 Gy decrease in the mean dose to the lung.
Along with the benefits of IMRT planning, VMAT also demonstrated a 24% reduction in the
volume of the heart receiving 30 Gy (31% vs 55%) when compared to 3D-CRT.3 While these
studies show a meaningful difference in the heart and lung dose they do not provide evidence of
lowering the dose to the liver or spinal cord volumes.3
Case Description
Patient Selection & Setup
Five retrospective patient cases were selected for this case study. All patients had biopsy
proven adenocarcinoma of the distal esophagus followed by chemotherapy and radiation therapy.
All 5 patients were simulated in the supine position, head first into the CT scanner. All patients
utilized a wing board with both arms above their head to prevent them from entering the
treatment field. Two patients utilized a Vac-lok immobilization device overlaid on the wing board
to increase reproducibility and reduce set up error. A knee sponge was placed under the patients
knees for comfort. Three radiopaque markers were used laterally and anteriorly on the patients
skin at the time of simulation to aid in the location of isocenter for treatment planning.
All patients had a cone beam CT (CBCT) performed before treatment 3 times a week to
ensure the location of the isocenter and kV on board imaging (OBI) the other 2 days. Image
guided radiotherapy (IGRT) aided in quantifying and addressing soft tissue set-up and kv- cone
beam CT (kV-CBCT) is becoming more commonly used for treatment verification.4

Target Delineation
The gross tumor volume (GTV) was contoured by the physician. An additional margin of
0.5 cm was added to the GTV volume and combined with the internal target volume (ITV) to
include extra margin for breathing. The ITV volume gave an additional margin of 0.5 cm in the
superior and inferior directions of the GTV volume. Both volumes were combined with an
additional margin of 1 cm to create the PTV. Using the radiation therapy oncology group
(RTOG) 1010 protocol for guidance on critical structure contouring for distal esophageal cancer,
organs identified and contoured were the spinal cord, liver, bilateral lungs (minus the PTV),
heart, kidneys, liver, stomach and spleen. Typically the spinal cord would be contoured on all CT
slices of the PTV as well as a centimeter above and below, but since the spinal cord is the
primary area of concern in this study, the organ was contoured on all slices of the CT scan to
ensure the dose reflected the total cord. Each lung was contoured individually on each slice as it
appeared on the CT scan and then a contouring operation was performed to combine the two
structures while excluding the PTV. This operation formed the bilateral lungs. The heart,
kidneys, stomach and spleen were contoured on each slice as it appeared on the CT scan.
Treatment Planning
In the United States, the most common definitive dose for radiation therapy treatment of
esophageal cancer treatments is 50- 50.4 Gy.2 This case study analyzed a dose of 45 Gy to the
PTV or primary area of disease and affected lymph nodes (PTV45Gy) and a 5.4 Gy boost to the
primary disease (PTV50.4Gy) totaling 50.4 Gy. The radiation was delivered at 1.8 Gy/ day, 5 days
per week over a 6 week period.
All 5 patients had both IMRT and VMAT treatment plans generated in the Pinnacle and
Eclipse TPS. The dosimetry of the plans was compared along with the OR. All plans were
designed for a 6MV linear accelerator with IMRT capabilities and the TPS used was capable of
both IMRT and VMAT treatment planning. The VMAT plans used both 360 and partial arcs
with opposing rotations (clockwise, counterclockwise) and the IMRT plans used 6-9 fields total
of varying gantry angles (Table 1). All isocenters were placed at the geometric isocenter of target
(PTV). A target volume constraint of at least 95% of the PTVs must be covered by the
prescription dose (Figure 1).
Three of the 5 patients had a 4-dimensional (4D-CT) simultaneously with their simulation
CT in order to observe any motion the target area might undergo. Respiration monitored CT

scans enabled the physician to accurately measure any motion of the target associated with
breathing. The amount of motion is taken into account in the ITV structure. This structure
allowed a reasonable amount of dose to the normal tissue while minimizing geographical miss.4
Some clinics do not have the equipment necessary to perform a 4D-CT in there clinic, in this
case extra margins need to be given to the simulation CT to take into account for possible
motion.5 Two of the 5 patients in this study did not have a 4D-CT scan preformed as they did not
have the equipment necessary, they had adequate margins added to the target volumes on the
treatment planning CT data set. During analysis of the 4D CT scans, it was found that two of the
three patients had phase errors larger than 5 mm which extended outside of the acceptable range
per the physician and gating was requested. The first patient was treated during the 30-70%
phase cycle and the second patient was treated during the 20-70% phase cycle. The third patient
did not have motion extending outside of the 5mm margin and gating was not used.
Esophageal cases show motion from respiration as well as from peristalsis
(gastrointestinal motion). Image guided radiation therapy (IGRT) is now used more frequently
than in the past because of this gastrointestinal motion.6 An alternative to using IGRT is to
increase the target volumes more to account for the possible motion. However, by adding
additional margins to the target volumes, an increase in side effects will likely occur.6The
physician may request tighter limits on nearby OR to ensure dose volume constraints are met.
Each of the planning techniques were optimized with the same OR objectives (Table 2).
Using the Emami1 constraints, the heart, right kidney and left kidney were all evaluated by the
volume receiving 50 Gy (V50) and 30 Gy (V30) as well as the maximum dose. The treatment
planning goal was to keep the volume of heart receiving 60 Gy (V60) less than 33%, the volume
receiving 45 Gy (V45) less than 67% and the maximum dose less than 40 Gy. The goal for the
kidneys was to keep the volume receiving 50 Gy (V50) below 33%, volume receiving 30 Gy (V30)
below 67% and the maximum dose less than 23 Gy. The bilateral lung was evaluated by the
mean dose less than 20 Gy and the volume receiving 20 Gy (V20), less than 37%. The cord was
evaluated by the maximum point dose of 45 Gy or less.

Plan Analysis & Evaluation

The integrity of each of the plans was compared using the dose to 100% of the PTV
(D100), dose to 95% of the PTV (D95) and the mean dose of the PTV (Dmean) (Table 3). All plans
must meet a target volume constraint of at least 95% of the prescription isodose line (Figure 2).
The average mean dose (Dmean) of the PTV45Gy was 47.48Gy for VMAT and 46.45Gy for IMRT.
The average Dmean of the PTV5.4Gy was 5.5 Gy for VMAT and 5.55Gy for IMRT. The conformity
index (CI= volume of tissue receiving prescription dose/volume of PTV), homogeneity index
(HI) and MU were also evaluated (Table 4).7,8 Homogeneity index is a tool to aid in analyzing the
uniformity of dose in the target volume. In this case, the ratio of the dose to 2% of the PTV (D2)
to the dose to 98% of the PTV (D98) (HI=D2/D98) was used to determine HI. The average HI of
PTV45Gy was 1.05 for the VMAT plans and 1.07 for the IMRT plans; the average HI for PTV5.4Gy
was 1.07 for the VMAT plans and 1.09 for the IMRT plans. The average CI of PTV45Gy was
97.63% for the VMAT plans and 97.38% for the IMRT plans and for the PTV5.4Gy the average CI
was 95.22% for the VMAT plans and 95.42% for the IMRT plans. The OR constraints were all
met (Table 5, 6); the lowest maximum dose for the spinal cord was 21.79 Gy and lowest mean
dose for the spinal cord was 4.98 Gy, both found in plan five utilizing VMAT. The MUs were
also assessed and demonstrated the VMAT plans used about 16% less than the IMRT plans. The
lowest total MUs were found in the VMAT plan of patient 2. Not only did the VMAT plans use
fewer MUs than the IMRT plans but the total treatment time was much shorter. On average the
VMAT plans treated each arc in 60 seconds for a total treatment time of 2 minutes where the
IMRT plans treated each field in 30 seconds for a total treatment time of 4 minutes.
There were two patient plans that provided the best results for sparing dose to the spinal
cord dose. The plan for patient 5 utilizing VMAT demonstrated to be both the best on the spinal
cord maximum dose (21.79 Gy) and mean dose (4.98 Gy) while encompassing the PTV volumes
with 98.65% of the prescription dose. The plan for patient 2 provided a maximum cord dose of
26.84 Gy (mean of 9.75 Gy) and provided 95.71% prescription coverage on the PTV volumes.
Conclusion
Radiation therapy is currently a standard treatment for esophageal cancer. Current studies
show a meaningful difference in the heart and lung dose but do not provide evidence of lowering
the dose to the spinal cord or neighboring organs.3 While comparing two treatment planning
techniques, static IMRT to VMAT for distal esophageal cancer, researchers evaluated dose to the

OR. A dose of 45Gy to the PTV45Gy and an additional 5.4 Gy to the PTV50.4Gy totaling 50.4 Gy
was analyzed. The integrity of each plan was compared using the D100, D95 and the Dmean. The
average Dmean of the PTV45Gy was 47.48Gy for VMAT and 46.45Gy for IMRT respectively. The
average Dmean of the PTV5.4Gy was 5.5 Gy for VMAT and 5.55Gy for IMRT respectively. The OR
constraints were met in all plans with spinal cord maximum dose of 21.79 Gy and mean dose of
4.98 Gy, both found in the patient plan 5 utilizing VMAT. The MUs were also assessed and
demonstrated that the VMAT plans used roughly 16% less MUs than the IMRT plans. The most
optimal treatment plan in regards to PTV coverage and OR dose was shown in patient plan 5
utilizing VMAT. It demonstrated to provide the best dose distribution on the spinal cord with a
maximum dose of 21.79 Gy and a mean dose of 4.98 Gy while providing the PTV volumes with
98.65% of the prescription dose. In conclusion, the two treatment techniques proved to be similar
with regard to PTV coverage and OR dose. However, the spinal cord dose was less on the VMAT
plans for the five retrospective cases. The total MUs/treatment times were much different,
therefore, making VMAT more efficient than IMRT. For centers without VMAT capabilities, the
IMRT plans still demonstrated effectiveness in treating target volumes and sparing the critical
structure. A limitation of this case study is the small population of patients therefore future
research should include a larger population of patients to determine if findings are more
significant or additional implications that could be noted.

References
1

Emami B, Lyman J, Brown A, et al. Tolerance of normal tissue to therapeutic radiation. Int J
Radiat Oncol Biol Phys. 1991;21(1):109122.
http://dx.doi.org/10.1016/0360-3016(91)90171-Y

Brooks-Brunn JA. Esophageal cancer: an overview. Medsurg Nurs. 2000;9(5):248-54.

Lloyd S, Chang BW. Current strategies in chemoradiation for esophageal cancer. J

Gastrointest Oncol. 2014;5(3):156-165. http://dx.doi: 10.3978/j.issn.2078-6891.2014.033

Hawkins M, Aitken A, Hansen V, et al. Cone beam CT verification for esophageal cancer
impact of volume selected for image registration. Acta Oncol. 2011;50(8):1183-1190.
http://dx.doi:10.3109/0284186x.2011.572912

Patel AA, Wolfgang JA, Neimierko A, et al. Implications of respiratory motion as measured
by four- dimensional computed tomography for radiation treatment planning of esophageal
cancer. Int J Radiat Oncol Biol Phys. 2009;74(1):290-296.
http://dx.doi:10.1016/j.ijrobp.2008.12.060

Jensen AD, Grehn C, Nikoghosyan A, et al. Catch me if you can- the use of image guidance
in the radiotherapy of an unusual case of esophageal cancer. Strahlenter Onkol.2009;185(7):
469-473. http://dx.doi.10.1007/s00066-009-1935-6

Feuvret L, Noel G, Mazeron J, et al. Conformity index: a review. Int J Radiat Oncol Biol

Phys. 2006;64(2):333-342. http://dx.doi:10.1016/j.ijrobp.2005.09.028

Kataria K, Sharma K, Subramanu V, et al. Homogeneity index: an objective tool for
assessment of conformal radiation treatments. J Med Phys. 2012;37(3):207-213.
http://dx.doi.10.4103/0971-6203.103606

Figures

Figure 1. Dose comparison between IMRT and VMAT plans. The VMAT plan achieves a dose
greater than 95% to the PTV volume as well as smaller low dose spread at 30 Gy.

Figure 2. Comparison dose volume histogram (DVH) for the PTV, spinal cord, kidney, liver,
heart and bilateral lung between IMRT (triangle) and VMAT (square) for one of the patient plans.

Tables
Table 1. Beam arrangement defining number of arcs and static fields used in each retrospective
patient plans.
Treatment planning technique used
Patient
1
2
3
4
5

IMRT
6 co-planar beams
5 co-planar beams
7 co-planar beams
7 co-planar beams
6 co-planar beams

VMAT
1- partial arc
2- full arcs
2- full arcs
3- full arcs
3- partial arcs

Table 2. Treatment planning objectives for both IMRT and VMAT treatment techniques.
Organ at Risk
Spinal Cord
R Kidney
L Kidney
Heart
Bilateral Lungs

Dose volume limit objectives

Dose Limits
Volume
45 Gy
Max
20 Gy
Mean
23 Gy
Max
30 Gy
<67%
50 Gy
<33%
23 Gy
Max
30 Gy
<67%
50 Gy
<33%
40 Gy
Max
45 Gy
<67%
60 Gy
<33%
15 Gy
Mean
20 Gy
< 35%

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Table 3. PTV coverage at prescription dose, mean dose (Dmean), dose at 100% (D100), dose at 95%
(D95) for each of the 10 plans.
PTV 45 Gy
Patient 1
D100
D95
Dmean
Patient 2
D100
D95
Dmean
Patient 3
D100
D95
Dmean
Patient 4
D100
D95
Dmean
Patient 5
D100
D95
Dmean

PTV 5.4 Gy

IMRT

VMAT

IMRT

VMAT

43.5
45.59
46.65

44.17
45.65
46.88

5.33
5.46
5.57

5.23
5.45
5.64

44.88
46.82
46.02

43.59
45.29
46.18

5.01
5.44
5.52

5.07
5.44
5.57

42.74
45.47
46.19

43.01
45.53
46.46

5.24
5.47
5.56

5.2
5.52
5.62

41.82
45.18
46.939

43.04
45.35
46.25

4.24
5.14
5.55

4.98
5.37
5.54

42.97
45.53
46.46

43.39
45.29
49.74

5.26
5.15
5.55

5.3
5.37
5.54

Table 4. CI, HI and MU parameters for both treatment planning techniques.

Treatment planning
technique
Parameter
VMAT
IMRT
Conformity Index
Mean
1.06
1.08
Range
0.1
0.15
Homogeneity
Mean
96.54%
96.31%
Range
5.84%
14.77%
MU per plan
Patient 1
686
662
Patient 2
584
800
Patient 3
1202
1580
Patient 4
1092
1700
Patient 5
954
929

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Table 5. Organs at risk for IMRT technique using Emami1 dose guidelines in Gy unless
otherwise noted.
IMRT
Patient 1
Patient 2
Patient 3
Patient 4
Patient 5
Kidney Rt
Max
43.62
24.86
5.76
46.68
0.73
67%
5.82
1.51
0.5
9.92
0.18
33%
18.56
6.97
0.95
15.48
0.28
Kidney Lt
Max
45.91
46.1
2.46
50.1
0
67%
0.09
0.05
0.41
12.08
0
33%
25.77
18.28
0.8
16.18
0
Heart
Max
48.72
54.54
50.75
54.01
52.33
67%
20.23
20.78
22.66
16.6
12.3
33%
30.48
35.46
32.73
29.59
18.41
Lung
Mean
10.28
14.61
9.18
8.41
6.65
V20
19%
31%
17.28%
19.96%
2.06%
Spinal Cord
Max
36.2
36.2
42.36
37.82
28.72
Mean
15.42
15.42
18.81
20.44
7.16
Table 6. Organs at risk for VMAT technique using Emami1 dose guidelines in Gy unless
otherwise noted.
VMAT
Patient 1
Patient 2
Patient 3
Patient 4
Patient 5
Kidney Rt
Max
43.94
28.74
7.13
45.41
0.81
67%
4.13
2.4
0.68
11.52
0.2
33%
17.18
12.36
1.31
17.55
0.31
Kidney Lt
Max
45.85
47.03
2.37
49.24
0
67%
5.54
6.32
0.43
10.02
0
33%
28.26
19.78
0.816
15.77
0
Heart
Max
54.53
54.5
50.83
52.81
52.59
67%
20.25
16.51
12.71
16.6
10.57
33%
35.46
21.56
20.8
24.21
16.01
Lung
Mean
10.74
16.72
8.63
8.41
7.73
V20
24%
21%
15.18%
12.20%
3.55%
Spinal Cord
Max
42.83
26.84
33.04
38.65
21.79
Mean
10.87
9.75
12.51
20.56
4.98