David Shepard

Swedish Cancer Institute

Seattle, WA
VMAT Treatment Planning
Acknowledgments
Vivek Mehta
Daliang Cao
Min Rao
Fan Chen
Kevin Brown
Rajinder Dhada
Ke Sheng
Disclaimer
Our IMAT work is sponsored in
part through a grant from Elekta.
1)To provide an overview of VMAT capable
treatment planning systems.
2)To review VMAT planning techniques and
tools for creating optimal VMAT plans
3)To examine the quality of plans that can be
obtained using VMAT
Objectives
VMAT Treatment Planning
IMAT Inverse Planning Solutions
Varian Eclipse RapidArc
Philips Pinnacle SmartArc
Elekta ERGO++
Elekta Monaco VMAT
Nucletron Oncentra MasterPlan VMAT
Siemens/Prowess Prowess Panther
Varian Eclipse
Planning is performed using Direct Aperture Optimization.
Typical plan uses 1 arc with 177 control points.
For some cases, multiple arcs are use to improve the plan
quality or provide adequate coverage of large targets.
DAO Optimization (1)
A simulated annealing algorithm is used to
optimize the MLC leaf positions and aperture
weights.
After each change in an MLC leaf position,
the algorithm checks to see if any of the
delivery constraints are violated. If so, the
change is rejected.
Otherwise, the change is accepted based on
the rules of simulated annealing.
The key feature of DAO is that all of the
delivery constraints are included directly
into the IMAT optimization.
DAO Optimization (2)
Eclipse VMAT
In Ottos paper, he used DAO to
produced IMAT plans.
Key innovations:
1. Focused on a single arc approach with more
control points in the single arc. Termed VMAT.
2. Progressive sampling was used to improve the
speed of the algorithm.
This is the approach utilized in Eclipse
Varian Eclipse
Composite dose for H&N patient treated at UMMS.
Initial = 50.4 Gy, SFB1 = 9Gy, SFB2=10.8Gy
Courtesy of Warren DSouza
Varian Eclipse
Lt.
Parotid
Spinal
Cord
Mandible
PTV1
PTV2
PTV3
Initial plan and SFB1 used 2 arcs, SFB2 used 1 arc
Delivery time = 1.5 minutes per arc
Courtesy of Warren DSouza
Philips Pinnacle
3
SmartArc
Philips Pinnacle - SmartArc
SmartArc is an extension of the DMPO
planning functionality in Pinnacle.
The SmartArc planning tools were
developed by RaySearch (Stockholm).
Courtesy of Philips Medical
Pancreas Case Treated with SmartArc
4500 cGy delivered in 25 fractions
1 arc, 338 MUs, Delivery time = 1.6 minutes
Pancreas Case Treated with SmartArc
PTV
Liver
Lt.
Kidney
Sp.
Cord
Rt.
Kidney
Summary From Initial Cases @ SCI
80 cases treated including lung, HN, liver,
pancreas, esophagus, brain, and chest wall.
1 arc used in 60% of cases
2 arcs used in 40% of cases.
Average delivery time (Elekta Linac):
1 arc cases = 1.9 minutes
2 arc cases = 3.9 minutes
Elekta VMAT
Anatomy based inverse (Ergo++).
Full inverse planning solution (Monaco)
Ergo++
TPS originally designed for stereotactic
radiosurgery with dynamic arc capabilities.
For VMAT, Ergo++ designs the beam
shapes based simply on the patients
anatomy.
The beam weights within a given arc are
then optimized.
Anatomy Based Inverse Planning
Plan Quality
Anatomy Based Inverse Planning
Plan Quality
Solid lines =Anatomy based VMAT
Dashed =Aperture based VMAT
GTV PTV
Lung
Heart
Sp Cord
Aperture Based Inverse Planning
Plan Quality
Anatomy Based Inverse Planning
Plan Quality
This solid =anatomy based VMAT
Thick solid =fluence based VMAT
Dashed =anatomy based VMAT
Anatomy based inverse planning for IMAT:
10
20%
20%
20%
20%
20%
1. Directly optimizes the MLC leaf positions
2. Sequences fluence maps into IMAT arcs.
3. May fail to produce uniform target doses
for highly complex targets.
4. Requires progressive sampling
5. Utilizes a sweeping window delivery
technique.
Answer:
Anatomy based inverse planning may fail
to produce uniform target doses for
complex cases.
References:
1. A Comparison of Treatment Planning and Delivery of VMAT Using Anatomy Based and
Fluence Based Inverse Planning with Step and Shoot IMRT, Med. Phys. 36, 2556 (2009);
2. Aperture Based Inverse Planning, Intensity Modulated Radiation Therapy The State
of the Art, Edited by J atinder R. Palta and T. Rockwell Mackie, D.M Shepard, M.A. Earl,
C.X. Yu, and Y. Xiao, Medical Physics Publishing, Madison, WI, 2003.
Monaco VMAT
Monaco is an IMRT-only TPS.
3 key features: (1) Monte Carlo dose
calculation; (2) Biology based IMRT
optimization; (3) VMAT inverse planning.
Monaco Background
Optimized fluence maps are produced at a
series of discrete beam angles.
These optimized fluence are then converted
into deliverable VMAT arcs.
Monaco VMAT Algorithm
Monaco produces plans using a sweeping
leaf sequencer where the leaves move
unidirectionally across the field.
The leaf movement continues to alternate
between sectors of the arc.
Monaco Sweeping Window
Monaco VMAT
Case #1 - Brain
180 cGy/fraction, 320 MU
Delivery time = 4 min. 40 sec.
Monaco VMAT
Case #2 - Prostate
180 cGy/fraction, 678 MU
Delivery time = 3 min 54 sec
Coronal
3mm/3%
Sagittal
3mm/3%
Ion
Chamber *
Delivery
time
Pelvis 99.7% 99.9% -1.8% 330
Esophagus 99.6% 97.3% 0.9% 414
Pancreas 99.8% 99.7% -1.7% 404
Brain 98.6% 98.0% -2.0% 403
Prostate 99.6% 99.1% -2.3% 349
HN 96.4% 96.0% -3.3% 8 48
Verification of Monaco VMAT: Matrixx and Ion Chamber
* Ion chamber data= (Measured Planned)/Planned
Nucletron Oncentra VMAT
Oncentra VMAT module was developed by
RaySearch Laboratories.
RaySearch also developed the SmartArc module
for Pinnacle.
Underlying VMAT planning engine is very similar.
VMAT (3%,3mm)
planned
measured
H&N Verification
Siemens/Prowess CBT
Prowess Direct Aperture Optimization
algorithm is used to develop VMAT plans for
delivery on Siemens linacs using Siemens
cone beam therapy (CBT) technique.
VMAT Plan Design
Single arc vs. Multi-arc delivery
Coplanar vs. Noncoplanar
Single vs. Multi Arc
Increasing the number of arcs provides
additional flexibility in shaping the dose
distribution.
The key questions are which cases benefit
from the use of multiple arcs and what
number of arcs should be used.
# of arcs
1 arc vs. 2 arcs
1 arc vs. 2 arcs
1 arc vs. 2 arcs
Solid lines: 2 arcs
Dashed lines: 1 arc
Delivery time: 1 arc= 124 sec, 2 arcs = 181 sec
What treatment site would most likely
see a dosimetric benefit to increasing
the # of VMAT arcs to more than 1?
20%
20%
20%
20%
20%
10
1. Lung
2. Prostate
3. Brain
4. Pancreas
5. Head & Neck
Answer:
Due to the complex target volumes and
the frequent use of multiple prescription
levels head & neck cases are most likely
to see significant dosimetric improvement
when using more than 1 VMAT arc.
Reference:
Single-Arc IMRT?, Thomas Bortfeld and Steve Webb, Physics in
Medicine and Biology, Volume 54, Number 1
Coplanar vs. Non-coplanar VMAT
Dosimetric Comparison of IMAT with
Conventional IMRT Delivery Techniques
VMAT vs. Tomotherapy:
Comparison Study
Collaborative study between Swedish
Cancer Institute and University of Virginia.
6 prostate, 6 head-and-neck, and 6 lung
cases were selected for this study.
Fixed field IMRT, VMAT, and Tomotherapy
were compared in terms of plan quality,
delivery time, and delivery accuracy.
Lung Case
Helical Tomotherapy 1-arc VMAT
Lung Case
Helical Tomotherapy 1-arc VMAT
Lung Case
GTV
PTV
heart
Delivery time for VMAT plan was 204
Delivery time for the Tomotherapy plan was 544
Delivery time for fixed field IMRT was 726
Thick solid lines: VMAT
Dashed lines: Tomo
Thin solid: 7 Field IMRT
Head & Neck Case #1
Two targets with prescription levels of 5040 and 4500 cGy
Helical Tomotherapy
2-arc VMAT
Head & Neck Case #1
Two targets with prescription levels of 5040 and 4500 cGy
Helical Tomotherapy
2-arc VMAT
Average V95: Tomotherapy = 98.4% and VMAT = 98.6%
Max cord dose: Tomotherapy = 34.4 Gy and VMAT = 21.6 Gy
Mean parotids dose: Tomotherapy = 12.1 GY and VMAT = 12.6 Gy.
Solid lines: VMAT
Dashed lines: Tomo
GTV
PTV1
PTV2
LT Parotid
RT Parotid
Cord
Head & Neck Case #1
Solid lines: VMAT
Dashed lines: Tomo
GTV
PTV1
PTV2
LT Parotid
RT Parotid
Cord
Delivery time for VMAT plan was 425
Delivery time for the Helical Tomotherapy plan was 907
Head & Neck Case #1
H&N Example #2
PTV70
PTV60
PTV66
2 arcs, 512 monitor units
Deliver time = 4 minutes 7 seconds
Solid = SmartArc Dashed = Tomotherapy
H&N Example #2
PTV70
PTV60
PTV66
Cord
Lt.
Parotid
Rt.
Parotid
PTV50
Lt.
Parotid
H&N Example #3
SmartArc Plan
Thick solid lines: VMAT
Dashed lines: Tomo
Thin solid: 9 Field IMRT
Future Developments
With the current HiArt system, the jaw width
and the couch speed are set to constant
values for each plan.
In 2011, Tomotherapy Inc. will offer a new
option with dynamic jaw motion and dynamic
couch motion.
Initial studies indicate that the dynamic jaw
capability should significantly reduce
tomotherapy treatment times.
VMAT Planning - Summary
1. All major planning vendors now offer inverse
planning solutions for VMAT with varying
levels of robustness.
2. Initial work on VMAT has largely focused on
single arc coplanar delivery. The advantages
of using multiple arcs and non-coplanar
beams are now being more fully explored.
3. With current technology, VMAT can provide
similar plan quality as current tomotherapy
systems with a more efficient delivery.
Treatment plans were
developed using
forward planning or
simple beam shaping
based on the patients
anatomy.
The dose rate was
constant as the
gantry rotated around
the patient.
First Generation IMAT
2000-2007
Treatment plans with
full inverse planning.
The dose rate varies
as the gantry rotates
around the patient.
Next Generation IMAT
2008-
SmartArc Planning Steps
1. Add a dynamic arc beam
2. Specify couch, collimator, and beam angles
3. Specify dose objectives
4. Specify SmartArc optimization parameters
5. Optimize
6. Compute final convolution dose
Courtesy Kevin Reynolds
Monaco VMAT
Case #3 Pelvic Mass
180 cGy/fraction, 463 MU
Delivery time = 4 min 40 sec
Monaco VMAT
Case #3 Pelvic Mass
SmartArc Optimization (1)
1. Beams are generated at the start and
the stop angles and at 24 increments
from the start angle.
2. A fluence map optimization is
performed.
3. The fluence maps are sequenced and
filtered so that there are only 2 control
points per initial beam angle.
Courtesy of Philips Medical
SmartArc Optimization (2)
4. These control points are distributed to
adjacent gantry angles and additional
control points are added to achieve the
desired final gantry spacing.
5. All control points are processed to comply
with the motion constraints of VMAT.
Courtesy of Philips Medical
SmartArc Optimization (3)
6. The DMPO algorithm is applied with an
aperture based optimization that takes into
account all of the VMAT delivery constraints.
7. A final dose calculation is performed
followed by a segment weight optimization.
Courtesy of Philips Medical
Prostate Verification
1-arc VMAT (3%,1mm)
planned
measured
Clinical Implementation of
SmartArc @ SCI
We began using SmartArc clinically in
February 2009, and have treated 80
patients.
Dynamic Jaws/Dynamic Couch
DJ/DC couch plans were developed for 10
nasopharyngeal patients.
As compared with the traditional 2.5 cm jaw
setting, the mean integral dose was reduced
by 6.3% and the average delivery time was
reduced by 66%.
Prostate Case
SmartArc Plan
Thick solid lines: VMAT
Dashed lines: Tomo
Thin solid: 7 Field IMRT
Ergo++
Ergo++ designs simplified IMAT arcs
with each beam based on the
patients anatomy.
This can work well for simple targets
but can break down for more
complex target geometries.
With the latest advances in IMAT
planning and delivery, we can now test
if IMAT can serve as a true alternative
to tomotherapy in terms of plan quality
and delivery efficiency.