The Royal Marsden

VMAT in thoracic malignancies

Dr. Maria A. Hawkins

Consultant Clinical Oncology
The Royal Marsden Hospital NHS FT

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Disclosure

– received research funding from Elekta

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VMAT

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New technology competition

– Cyberknife - good marketing, intracranial sites

– Tomotherapy- “all in one” solution (IMRT only)

– Protons-costly, not yet proven to be superior in certain

tumour sites, not yet widely available

– VMAT- linac based technology, more precise treatment,

short delivery time, potentially more accessible
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VMAT

Further evolution of IMRT

– one/more gantry arcs

– Continuously varying
– Beam aperture
– Gantry speed
– Dose rate
Planning techniques-VMAT
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VMAT Benefits

– Faster treatment times

– Improved target dose conformality

– Beam modulation

– Reduced dose to OAR

– 3D volumetric imaging – necessary for delivery

accuracy
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Why speed matters?

– Patient comfort

– Intrafraction organ motion/Opportunity to use gating

– Biological effects-improved clinical outcomes

– Patient throughput increased

– Planning time - possibly faster once solution found

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Improved conformality/reduced OAR dose

– Reduce toxicity further

– Dose escalation

– Hypofractionation

– Re-treatment to radical doses

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3D volumetric imaging needed for VMAT

– Improves accuracy → set-up margin reduction

– Soft tissue visualization

– Opportunity to adapt treatment if tumour/patient changes

volume/shape
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Tumour sites – VMAT opportunities

– Replace IMRT prostate/H+N/Gynae

– Replace 3DCRT: GI-upper_lower/lung

– SBRT: lung/liver/paraspinal

– Palliative: vertebral body/H+N re-treatment

– Other sarcoma, CNS

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VMAT lung cancer

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3D conformal vs IMRT vs VMAT

Planning study
– 5CT datasets of patients treated with radical RT for
non-small cell lung cancer

9 plans
– IMRT 3, 5, 7, 9 fields coplanar
– IMRT 3, 5, 7, 9 fields non-coplanar
– VMAT

Brock ESTRO 2008

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3D conformal Radiotherapy

Brock ESTRO 2008

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IMRT plans VMAT

VMAT

5 F coplanar

7 F coplanar

Brock ESTRO 2008

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IMRT plans VMAT

Fields arrangement

Brock ESTRO 2008

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PTV 95% isodose coverage

Brock ESTRO 2008

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Lung V20 comparison

Brock ESTRO 2008

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Inoperable stage III Non-small Cell Lung Cancer

Conformal plan

Bedford Acta Oncol 2008

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Inoperable stage III Non-small Cell Lung Cancer

VMAT plan

Bedford Acta Oncol 2008

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1st patient treated

Combined DVH

GTV
PTV
Lungs
Spinal cord
oesophagus
heart

VMAT 3DCRT Bedford Acta Oncol 2008

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1st patient treated

Comparison of 3DCRT and VMAT

Parameter 3DCRT VMAT

PTV min 41Gy 43Gy

V20 35% 32%

Treatment time/# 180secs 90secs

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VMAT lung cancer

– VMAT offers same degree of PTV coverage

– Lung V20 similar

– VMAT is preferable because of significant shorter

times
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VMAT oesophagus
cancer

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Oesophagus

– Planning study 10 patients

– Gastro-oesophageal junction
– 54Gy/30#
– Compared with 3D
– Spare heart, liver, cord
– Better conformity index

Hawkins BJR 2011

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Sagital plan comparison

Hawkins BJR 2011
Purple=PTV
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Fig. 1a
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Continuous=clinical
Dashed=VMAT
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Fig. 3
Heart volume receiving 35Gy

70%

60%
% Volume at 35Gy

50%

40%

30%

20%

10%

0%
1 2 3 4 5 6 7 8 9 10

patient
Clinical plan VMAT plan
Hawkins BJR 2011
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OAR

Clinical plan VMAT p

Lungs V20 (%) 15%±6% 15%±5% 0.87

Mean lung dose (Gy) 8.2±2 9.7±2.7 0.02

Heart V35 (%) 44%±14% 22%±4% 0.01

Cord max (Gy) 35.8±1 29.5±5 0.02

Hawkins BJR 2011

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VMAT Oesophageal cancer

– VMAT offers same degree of PTV coverage

– Significant reduction of heart dose

– VMAT is preferable because of significant shorter

times
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VMAT clinical data

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The Royal Marsden data thorax patients

– 34 patients treated between July 2008-June 2010

– Age: mean 67 years (range: 43-89)
– Sex: M/F=17/8
– Lung ca=28, dose 50-64Gy in 2Gy/#
– ABC used in 11 lung patients
– 6 lung cancer SBRT part of study (not reported here)

– oesophagus ca=6 with concurrent capecitabine 54Gy

in 1.8Gy/#

Ahmed Hawkins 2011

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Lung and oesophagus DVH parameters

ORGAN VOLUME MEAN (RANGE)

Lung V5Gy 53.3 (17-92) %

(all patients) V10Gy 38.8 (8-76) %
V20Gy 18.1 (5-53) %

V30Gy 10.4 (2-27) %

V35Gy 7.6 (1-21) %

MLD 11.1 (3-19) Gy

Oesophagus V35Gy 22.3 (0-77) %

(lung patients only) V50Gy 13.5 (0-57) %

V60Gy 7.1 (0-49) %

Ahmed Hawkins 2011

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Acute toxicity (1-90days) Grade ≥1

n=28
Toxicity grade Gr1 Gr2 Gr3
Dysphagia* 10% 33% -
Lethargy 8% 32% 1
Chest pain* - 3
Pneumonitis 29% 7% 3%

Pleural effusion 3 - -
Other Platelets 3.5% Dyspnoea
Skin7% PE
Nausea 7% Pneumonia

*lung patients only Ahmed Hawkins 2011

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Acute toxicity (1-90days)

RT stopped early 4 cases

– 36Gy/50Gy platelets dropping
– 52Gy/64Gy Dyspnoea gr3
– 10Gy/64Gy PE
– 50Gy/64Gy brain metastases

All toxicities resolved at 3 months

Ahmed Hawkins 2011

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Localised pneumonitis 60Gy/8# at 3 mo post RT

Planning and Dg CT fusion
Diagnostic CT

Pink =PTV
Red=100%
Yellow=95%
Light green=70%
Brown=50%
Dark green=5%
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Conclusion

– VMAT well tolerated

– Pneumonitis rates were low Grade 2 <10%

– This could be due combination VMAT and ABC

– Dysphagia rates acceptable – consider oesophageal

dose constraint

Ahmed Hawkins 2011

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VMAT studies

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VISuAL Study:
VMAT Image-guided Stereotactic
Arc therapy for small volume
Lung tumours
PI: Prof. M. Brada

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VISuAL Study

– To assess the feasibility of delivery of

hypofractionated RT for early-stage NSCLC
– 60Gy/8#/3 weeks

– using ABC / CBCT / VMAT

– To assess associated toxicity and

outcomes
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First patient: VMAT plan

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First patient: CBCT & on-line match

Pre match

Post match
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VMAT clinical implementation

– Identify groups that benefit

– Need to develop studies to confirm dose modelling

predictions

– Keep the plan objectives and goals realistic!

– Planning +verification ---more time

– Faster delivery ---more patients

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Acknowledgements
William Beaumont Hospital

Prof. Mike Brada James Bedford

Helen McNair Jim Warrington
Juliet Brock Fiona McDonald
Merina Ahmed
Judith Christian
Diana Tait
Ellen Donovan
Phil Evans

RMH Physics
RMH radiographers
RMH Imaging
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Thank you

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