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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
Medical Dosimetry Program at the University of Wisconsin-La Crosse, WI

Abstract

Keywords:

Introduction

Individuals with lung cancer often possess risk factors for cardiovascular disease or pre-
existing cardiac conditions. The American Cancer Society identifies lung cancer as the most
common and fatal cancer worldwide.1 An estimated 238,340 new cases of lung cancer will be
diagnosed and approximately 127,070 deaths will occur from lung cancer in 2023.1 Researchers
have concluded that the risk of a major adverse cardiac event (MACE) is elevated in non-small
cell lung cancer (NSCLC) patients in the 2 years following radiation therapy and that MACE can
be independently predicted by cardiac radiation dose exposure.3,4 Researchers suggested that
cardiac dose reduction during radiation treatment planning is of significance and future trials
should be investigated.3,4
Radiation induced damage to the heart and substructures is linked to severe cardiac
events and death.3 A trial conducted by the Radiation Therapy Oncology Group (RTOG 0617)
compared the average survival of patients receiving concurrent chemotherapy given high-dose
radiation therapy as opposed to standard dose radiation therapy.4 An incidental result of this trial
was the revelation that higher doses to the heart resulted in an increased risk of
mortality.3According to Qualitative Analyses of Normal Tissue Effects in the Clinic
(QUANTEC), heart dose to 100% of the volume, should receive < 40 Gy.3-6 Through the use of
advanced treatment planning techniques such as volumetric-modulated arc therapy (VMAT),
radiation doses to the heart and substructures can be minimized; therefore, reducing cardiac
toxicity.
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Volumetric-modulated arc therapy, which was first introduced in 2007, can be described
as an innovative planning and delivery technique where the multi-leaf collimator (MLC) and
dose rate fluctuate while the linear accelerator gantry moves in a continuous arc around the
patient.6 When compared to fixed field intensity-modulated radiation therapy (IMRT) and three-
dimensional conformal radiation therapy (3D-CRT), VMAT is the preferred method for treating
lung cancer.6-8 Volumetric-modulated arc therapy enables enhanced precision in radiation
delivery, resulting in improved conformal dose distributions and escalation of radiation dose to
the tumor while protecting critical structures like the heart. 6-8 In an effort to spare critical
structures such as the heart, the degree of gantry arc angle and treatment planning objectives can
be manipulated to avoid entering or exiting the critical structure.9,10
Researchers showed that when treating left sided lung tumors, mean heart doses > 40 Gy
increased the potential for cardiac toxicity.3 Treatment planning techniques such as VMAT, may
be utilized to assist in minimizing mean heart dose. The problem is that when treating tumors in
the left lung near the heart, the heart can receive mean doses > 40 Gy; therefore, increasing the
potential for cardiac toxicity. The purpose of this study was to evaluate 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% planning target volume (PTV) coverage. Researchers
tested the hypothesis (H1A) that using 2 partial VMAT arcs compared to 2 full 360-degree
VMAT arcs for left-sided lung tumors, will effectively reduce the mean dose to the heart to < 40
Gy while still maintaining 95% PTV coverage.
Methods and Materials
Patient Selection & Setup
Twenty patients were chosen for this retrospective study. Seventeen patients were treated
with a motion management device and 3 patients were treated while free breathing. The inclusion
criteria were patients with left-sided lung tumors at the level with the heart, treated using VMAT.
Patients with right lung tumors, mediastinal tumors, boost volumes and lymph node involvement
were excluded from this study. Daily patient set up and immobilization devices established in CT
simulation included: thorax board, blue pad, arms above head in cup holders, knee-fix wedge,
and a carbon fiber head rest (Figure 1). Patients were oriented in the headfirst supine position for
the CT scan. The slice thickness of the CT scans was 3.0 mm with imaging parameters that
included the apex of the lung extending through the diaphragm.
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Contours
All patient contours were drawn using version 16.1 of the Eclipse treatment planning
system (TPS). The organs at risk (OAR) contours utilized for each plan included: heart, great
vessels, left lung, right lung, main bronchus, chest wall, spinal cord, and esophagus. The target
volume for this study was the PTV. The generation of the PTV was dependent upon motion
management. For the patients utilizing a motion management device, the physician defined the
Gross Tumor Volume (GTV) on the breath hold CT scan, and a certified medical dosimetrist
added an automatic expansion of 0.5 cm to 0.8 cm from the GTV to form the PTV. Alternatively,
for patients who were treated with free breathing, the physician defined the GTV on each phase
of the 4DCT scan. A physicist then created the Internal Gross Tumor Volume (IGTV) based on
the 4D average, and a certified medical dosimetrist added an automatic expansion of 0.5 cm to
0.8 cm around the IGTV to establish the PTV.

Treatment Planning
In this study, treatment planning utilized Eclipse version 16.1, with the Anisotropic
Analytical Algorithm. All patients were planned on a Varian Truebeam linear accelerator, which
utilized MLCs with a width of 0.5cm. The isocenter was placed in the center of the PTV volume.
The prescription followed a stereotactic body radiation therapy regime of 10 Gy per fraction for
5 fractions to a total dose of 50 Gy. A beam energy of 6 MV Flattening Filter Free (FFF) was
used with a dose rate of 1400 MU/min (monitor unit per minute). Two plans were created for
each patient. The first plan utilized 2 full 360-degree arcs ensuring there would be no collision of
the gantry with the patient or treatment table. One clockwise arc rotating from 181-degrees to
179-degrees, with a 30-degree collimator rotation and one counter-clockwise arc rotating from
179-degrees to 181-degrees with a 330-degree collimator rotation. This arc configuration did not
avoid the radiation beam from entering through the heart and therefore was denoted as “without
avoidance.” The second plan utilized 2 partial arcs that did avoid the radiation beam from
entering through the heart, denoted as “with avoidance.” The first arc rotated clockwise from 10-
degrees LAO position to 170-degrees LPO position with a 30-degree collimator rotation and the
second arc rotated counterclockwise from 170-degrees to 10-degrees with a collimator rotation
of 330-degrees. During optimization, objectives were adjusted on OAR as needed as well as on
the PTV to ensure coverage was met. Upon completion of the optimization process, the dose
value histogram (DVH) was assessed.
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Plan Comparison
PTV coverage and mean heart dose were the primary metrics evaluated for this study.
Left lung dose and esophagus dose were evaluated to ensure there were no significant changes to
these critical structures. For each plan, the mean heart dose was required to be < 40 Gy while
maintaining 95% dose coverage of the PTV volume. This evaluation identified arc arrangements
that best achieved the lowest mean heart dose, with no significant changes to left lung dose or
esophagus dose, while preserving necessary coverage of the PTV.

Statistical Analysis
For this study, each patient’s plans were examined individually for data collection.
Specifically, a one-tailed t-test was used to determine if the average mean heart dose is lower for
the partial arc treatment plans. To consider the data as statistically significant a P value of < .05
was applied.
Results
Target Coverage
To maintain consistency between heart avoidance and no heart avoidance treatment
plans, all plans were normalized so that at least 95% of the dose, 47.5 Gy, encompassed 100% of
the PTV. For the partial arc heart avoidance treatment plans, the PTV dose ranged from 50 Gy to
51.1 Gy. For the full arc without heart avoidance treatment plans the PTV doses ranged from
49.8 Gy to 50.9 Gy.
Mean Heart Dose
The mean heart dose for the heart avoidance plans ranged from 0.156 Gy to 8.248 Gy and
0.149 Gy to 8.656 Gy for the plans without heart avoidance (Figure 2). Mean heart doses were
lower in 19 out of 20 patients (Table 1). The most significant difference was observed for patient
2, where mean heart dose was lowered by 1.03 Gy due to the use of partial arcs to assist in
avoiding the heart. In one patient the mean heart dose was 0.007 Gy higher in the treatment plan
with avoidance. Statistical analysis of the data utilized a one-tailed t-test which revealed a P
value of < 0.001 when evaluating mean heart dose with partial arcs, confirming this study as
statistically significant. Therefore, the null hypothesis (H10) was rejected.
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Discussion
Cardiac toxicity remains an issue for patients with lung cancer that are receiving radiation
therapy.3,4 Atkins et al,3 highlight the importance of avoiding high cardiac doses during radiation
therapy treatments through modifications in the treatment planning process. The results from our
study suggest that partial arc VMAT configurations play a significant role in reducing mean dose
to the heart when treating tumors in the left lung near the heart (Figure 2) (Table 1).
It is essential to maintain acceptable dose coverage to target volumes when modifying
treatment planning techniques to limit OAR radiation therapy dose. This study has revealed that
it is possible to attain comparable target volume coverage while concurrently reducing radiation
dose to critical OARs, notably the heart, left lung, and esophagus, by utilizing VMAT during
radiation treatment planning. This finding highlights the significance of optimizing treatment
planning methodologies to provide effective tumor irradiation while mitigating potential adverse
effects on surrounding healthy tissues, thereby enhancing the overall outcome for patients.
This retrospective study provides evidence that modifying gantry arc configurations
during treatment planning can reduce mean heart dose. The most significant difference in
lowering mean heart dose with heart avoidance configurations was observed in patient 2 where
mean heart dose was lowered by 1.03 Gy (Figure 2) (Table 1). However, there was an increase in
mean heart dose with heart avoidance configurations seen in patient 4 (Figure 2) (Table 1). This
discrepancy was due to the tumor location being closer to the heart as well as trying to maintain
PTV coverage with the heart avoidance gantry configurations.
Conclusion
The problem is that when treating tumors in the left lung near the heart, the heart can
receive doses > 40 Gy; therefore, increasing the potential for cardiac toxicity. The purpose of this
retrospective study was to determine VMAT configurations for left sided lung tumors near the
heart that would deliver a mean heart dose of < 40 Gy while maintaining 95% PTV coverage.
Researchers in the current study showed a benefit in using partial arc configurations that avoided
the heart, leading to a lower mean heart dose. Statistical analysis from this retrospective study
revealed a P value of < 0.001 validating the significance of using partial arc VMAT
configurations when treating tumors in the left lung near the heart. When evaluating OAR
metrics, no notable differences were observed in dose to the left lung or esophagus. PTV
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coverage remained consistent between both arc configurations with heart avoidance and without
heart avoidance.
The limitations of this study included data collection from one institution on a limited
population size (n=20) using only a Varian Truebeam linear accelerator and Eclipse TPS with the
Anisotropic Analytical Algorithm. Suggestions for further research include using a larger
population size across multiple clinical institutions with different TPS and various linear
accelerator models to help justify this study. Furthermore, investigating tumors in the left lung
that are not centrally located should be researched as well as more in-depth OAR metric
evaluation.
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
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Figures
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Figure 1. Patient immobilization devices utilized in CT simulation and daily treatment set-up.
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Figure 2. Comparison of mean heart dose with and without heart avoidance.

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
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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