Transcript Study - Toby Shutters BS, RT(R)
Slide 1
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 2
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 3
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 4
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 5
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 6
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 7
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 8
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 9
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 10
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 11
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 12
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 13
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 14
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 15
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 16
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 17
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 18
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 19
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 20
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 21
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 22
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 23
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 24
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 25
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 26
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 27
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 28
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 29
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 2
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 3
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 4
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 5
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 6
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 7
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 8
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 9
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 10
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 11
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 12
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 13
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 14
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 15
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 16
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 17
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 18
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 19
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 20
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 21
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 22
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 23
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 24
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 25
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 26
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 27
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 28
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option
Slide 29
Authored by:
Toby Shutters, B.S. RT(R) (T)
Indiana University School of Medicine
Medical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMD
Richard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandel
methoden/uitwendigebestraling/128828/314368/
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
Radiation
Conventional External
Beam
SBRT
Large Daily Fractions
Small Daily Fractions
Total Fractions 1 to 5
Total Fractions 27 to 33
3 year local control rates of up
5 year survival rate of 10 to
to 98%
30%
Increases in late toxicities
Location
Dosimetrically challenging
Tumors adjacent to the chest wall area
Deliver high conformal doses
Minimize critical structure doses
Late toxicities
Chest wall pain
Rib fractures
Toxicities
Natonal Institute Common Terminology Criteria for
Adverse Events
Grade 1
Mild pain
Grade 2
Moderate pain
Grade 3
Severe pain
Grade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or
greater at 30 Gy with
15cc’s
30% risk at 30 Gy with
40 cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
Dunlap et al
30 Gy in 3-5 fractions
should be less than
30cc’s
50 Gy greater incidence
of rib fracture or chest
wall pain
This study retrospectively analyzed three planning
techniques to determine if a there was a dosimetric advantage
utilizing noncoplanar geometry. All five patients had adjacent or
invasive chest wall lesions. The plans were evaluated using the
Conformality Index from RTOG 0813 and 0915. Chest wall and
rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials
5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continued
Two sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning Techniques
Coplanar (COP)
No couch rotations
Mixed Planar (MP)
Some couch rotations, some not
Non-coplanar (NCP)
All couch rotations
Three Planning Techniques: COP
Field Label
Gantry Angle
Couch Rotation
AP
0
0
RAO 333
333
0
RAO 305
305
0
RAO 278
0
RPO 250
278
0
250
RPO 223
223
0
RPO 195
195
0
LPO 168
168
0
LPO 140
140
0
LPO 113
113
0
LAO 85
85
0
LAO 58
58
0
LAO 30
30
0
0
Three Planning Techniques: MP
Field Label
Gantry Angle
Couch Rotation
RPO
210
0
RT LAT
270
0
RAO
315
0
AIO
340
90
ASO
30
90
LAO
50
0
LSO
90
20
LIO
90
340
LPIO
160
340
PA
180
0
Three Planning Techniques: NCP
Field Label
Gantry Angle
Couch Rotation
LPSO 2
LPSO 1
LAIO 2
LASO 1
LAIO 1
LASO 1
LAIO 1
RASO 2
RAIO 2
RASO 1
RAIO 1
RPSO 2
RPIO 1
RPSO 1
160
122
101
79
58
37
19
350
323
302
281
259
238
217
50
18
345
15
342
16
306
306
26
342
10
345
15
345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy
95 % coverage of PTV
RTOG 0915 for OAR verification
Chest wall/rib volume at 2cm contour
DVH at V10 Gy, V30 Gy, V45 Gy, and V50 Gy
Conformality Index
Results
Conformality Index (CI)
RTOG 0813 and 0915
Optimum CI less than 1.2
Minor Deviations between 1.2 and less than 1.5
All three techniques
Optimal or minor deviations
40% or 6 out of 15 optimal
MP: met 1.2 for all but one patient
COP and NCP: met 1.2 one patient each
Conformality Index
Conformality Index
1.5
Results
1.4
Mixed
1.3
COP
1.2
NCP
1.1
1
1
2
3
Patient #
4
5
Chestwall Volume 30 Gy
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient#
P4
P5
Chestwall Volume 45 Gy
8
7
Volume (cc)
6
5
Mixed
COP
NCP
4
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Chestwall Volume 50 Gy
4.5
4
Volume (cc)
3.5
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 30 Gy
7
6
Volume (cc)
5
4
Mixed
COP
NCP
3
2
1
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 45 Gy
4
3.5
Volume (cc)
3
2.5
Mixed
COP
NCP
2
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 50 Gy
3.5
3
Volume (cc)
2.5
2
Mixed
COP
NCP
1.5
1
0.5
0
P1
P2
P3
Patient #
P4
P5
Synopsis
Dose/Volume relationship
Analysis of three different planning techniques for
dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
Chestwall Volume 10 Gy
200
180
160
Volume (cc)
140
120
Mixed
COP
NCP
100
80
60
40
20
0
P1
P2
P3
Patient #
P4
P5
Rib Volume 10 Gy
35
30
Volume (cc)
25
20
Mixed
COP
NCP
15
10
5
0
P1
P2
P3
Patient #
P4
P5
Conclusion
Cure for early stage NSCLC is surgical
Aging population has comorbidities
Medically inoperable offered SBRT
SBRT has late toxicities
Improved survival decrease toxicities
Analyzed 3 planning techniques for volumes and
conformality
NCP offers no dosimetric advantage increases
treatment time
MP is best option