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Adriana Dalea
DOS Clinical Practicum III

3D SBRT Lung Case Study

Stereotactic Body Radiation Therapy (SBRT) is a technique that uses high dose fractions
to be delivered to the tumors, and this shortens the treatment time for the patients and gives
better tumor control.1The Radiation Therapy Oncology Group (RTOG) developed for SBRT
treatment several protocols. Intensity Modulated Radiation Therapy (IMRT) or 3 Dimensional
Conformal Radiation Therapy (3D-CRT) can be used when treating patients with SBRT, based
on the chosen RTOG protocol for each individual case.
The patient chosen for this case study was treated with 3D SBRT for two lung lesions,
one in the left lung upper lobe, and the other one in the right lung upper lobe. The patient is a 74
year old male with a history of laryngeal cancer diagnosed in 1998 and currently with metastatic
rectal and lung cancer. In 1998, the patient diagnosis was T3N1M0 left true vocal fold squamous
cell laryngeal carcinoma. He underwent total laryngectomy, followed by 60 Gy of radiation
therapy. In July 2012 he was diagnosed with rectal adenocarcinoma. He received neoadjuvant
chemoRT, 50.4 Gy to the whole pelvis, followed by 5.4 Gy boost to the rectum. In November
2012, the patient had another pathology report that showed a 3.5 cm grade 2 adenocarcinoma of
the colon, infiltrating transmurraly. He was offered chemotherapy, which he refused. In October
2013, a PET scan showed a 0.9 cm RUL nodule and a 0.9 cm LUL nodule. After 8 months, a CT
scan demonstrated enlargement of the two lung nodules, RUL 1.2 cm and LUL 1.6 cm. After the
patients medical history was carefully analyzed by the radiation oncologist, the patient was
recommended to undergo stereotactic body radiotherapy to the RUL and LUL lesions in July
2014. The prescription was 54 Gy to be delivered in 3 fractions (18 Gy per fraction) to each of
the LUL PTV and RUL PTV, respectively.
The protocol to be followed was RTOG 0813, Seamless Phase I/II Study of Stereotactic
Lung Radiotherapy (SBRT) for Early Stage, Centrally Located, Non-Small Cell Lung Cancer
(NSCLC) in Medically Inoperable Patients.2 The protocol addresses a population of patients with
stage T1-2, N0, M0 non-small cell lung cancer, tumor size less or equal to 5 cm, who are not
candidates to a complete surgical resection in the opinion of a thoracic surgeon. Only the patients

with tumors within or touching the zone of the proximal bronchial tree or adjacent to mediastinal
or pericardial pleura can be treated under this protocol.
The patient underwent a CT 4 D simulation and was positioned supine on a body pro-lok
board, with the arms up. Sponges were placed under his knees and heels for better support and
comfort. (Figure 1) Marks were placed on the patients body.
After the scan was completed, the study was imported in the Eclipse 11 treatment
planning system. The radiation oncologist contoured the left and right lungs GTV, and a 0.5 cm
margin was added in order to determine the LUL PTV and RUL PTV. The organs at risk
contoured were left and right lung, heart, esophagus, spinal cord and carina (for positioning
reasons). Per the radiation oncology departments protocol, there were two plans created for each
of the PTVs, and each plan had a 13 beam arrangement. For the left lung, the gantry angles were:
0, 20, 40, 60, 80, 100, 120, 140, 160, 180, 200, 320 and 340. (Figure 2) The right lung had the
beams at the following gantry angles: 0, 20, 135, 155, 180, 200, 220, 240, 260, 280, 300, 320 and
340. (Figure 3) One of the requirements of the RTOG 0813 was that each field had to a
minimum of 3.5 cm. For the left lung, the MLCs were fitted to the PVT with a 0 cm margin. For
the right lung, the MLCs were fitted in an elliptical shape to the PTV and a 0.5 cm margin was
placed along the vertical axis only.
The calculations were done for both plans, and the normalization was done so 100% of
the dose covered 95% of the PTV. The RTOG 0813 protocol has certain guidelines and
constraints for SBRT treatment planning (Figures 5, 6, 7 and 8):
High Dose Spillage
Location
Any dose higher than 105% of the prescription dose should be located primarily within
the PTV. The cumulative volume of all tissue outside the PTV receiving a dose higher than
105% should be no more that 15% of the PTV volume.
In this patients situation, for the left upper lung plan, I converted the 105% isodose line
to a structure, and the volume was 18.6 cm3. The PTV volume was 21.3 cm3. Dividing 18.3 to
21.3 gave us the ratio of 0.87. Therefore, the percentage of the dose higher that 105% of the
prescription that went outside of the PTV, was 13%. This result was acceptable and met the
criteria of being less that 15%. Important to mention here is that when I created the original set
up, I put a 0.5 cm margin of the MLCs to the PTV on the y axis (the vertical one), and after

calculating, the 105% isodose line volume was higher, and the ratio between the 105% isodose
line volume to the PTV was higher than 15%. This meant that the high dose spillage occurred
more than acceptable outside of the PTV, in the normal tissues. This was the reason to fit the
MLCs to the PTV with a 0 cm margin.
For the RUL plan, the 105% isodose line volume was 18.6 cm3, and the PTV volume was
11.1 cm3. The ratio between the two was 1.68, meaning that the 105 % isodose line is 98.33 % of
the PTV.
Volume
The conformality of the PTV coverage was analyzed by making the ratio between the
volume of the 100% prescription isodose to the volume of the PTV. In the ideal situation, this
ratio should be less than 1.2. A deviation from the protocol of 1.5 would be considered minor
and would be acceptable. The values of the deviation for the LUL and RUL plans are presented
in Table 1 below.
Low Dose Spillage
This refers to the objective of obtaining a rapid falloff gradient in all directions beyond
the PTV extending to the normal tissue structures.
Location
The maximum total dose over all the fractions in Gy to any point 2 cm or greater away
from the PTV in any direction must be within the certain limits given by the RTOG 0813
protocol, based on the PTV volume. I created a structure for each plan containing all the organs
at 2 cm distance from the LUL PTV and RUL PTV, respectively. In this case, for the LUL (PTV
volume 21.3 cm3), the minor deviation should be less that 63, and for the RUL (PTV volume
11.1 cm3) should be less than 58. Both plans met the criteria. (Table 1)
Volume
The ratio of the volume of 50% of the prescription isodose to the volume of the PTV
must be no greater than the given R50% for the corresponding PTV volume. The 50% isodose
line volume for the LUL was 108.4 cm3, and for the RUL was 63 cm3. Dividing these values to
the PTV volumes, 21.3 cm3 and 11.1 cm3, respectively, the results obtained were 5.5 for the LUL
and 5.8 for the RUL, both representing minor deviations. (Table 1)
The percent of the lung receiving a total of 20 Gy or more, V20, was 12.1% for the left
lung and 4.4% for the right lung. For the left lung the value was more than 10 and less than 15,

resulting in a minor deviation. For the right lung, there was no deviation. The dose volume
histograms for both plans are represented in figures 9 and 10. All the organs at risk constraints
met the criteria for both plans, the plan sum dose volume histogram (DVH) is shown in figure
11.
I created a 10 field plan for the left lung lesion, to make a comparison with the 13 field
plan. All the criteria were met after calculating all the ratios, but the V20 had a value of 27.8,
which was not acceptable under this protocol. The 13 field arrangement was the best option for
this case. The 3D maximum dose was 124.3% for the left lung plan, and 121.3% for the right
lung. These values are acceptable for SBRT cases, when all the required criteria under the
protocol are met. The organs at risk values are listed in Table 2.
Working on this 3D SBRT case study was a great learning tool and helped me understand
the entire process to be followed when working on planning under certain protocols. Using the
isodose lines converted volumes and calculating the ratios to the target volumes was a new
concept and made me understand different aspects when analyzing the outcomes of delivering
high radiation dose in a hypo fractionated sequence.

References
1. Shi C, Tazi A, Fang DX, Iannuzzi C. Implementation and evaluation of modified
dynamic conformal arc (MDCA) technique for lung SBRT patients following RTOG
protocols. Medical Dosimetry. 2013;38(3): 287-290.
http://dx.doi.org/10.1016/j.meddos.2013.02.010
2. RTOG 0813 Protocol Information. Seamless Phase I/II Study of Stereotactic Lung
Radiotherapy (SBRT) for Early Stage, Centrally Located, Non-Small Cell Lung Cancer
(NSCLC) in Medically Inoperable Patients. RTOG Web site.
http://www.rtog.org/ClinicalTrials/ProtocolTable/StudyDetails.aspx?study=0813. March
6, 2013. Accessed, October 26, 2014.

Figures

Figure 1. Position of the patient during simulation.

Figure 2. Left lung beam arrangement.

Figure 4. Right lung beam arrangement.

Figure 5. Left upper lung isodose converted structures representation.

Figure 6. Left upper lung isodose lines and 3D max in axial view.

Figure 7. Right upper lung isodose converted structures representation.

Figure 8. Right upper lung isodose lines in axial view.

Figure 9. DVH of the left upper lung plan.

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Figure 10. DVH of the right upper lung plan.

Figure 11. DVH of the plan sum.

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Tables
PTV Volume

Ratio of

Ratio of 50%

Maximum

Percent of

(cc)

Prescription Isodose

Prescription Isodose

Dose (in % of

Lung

Volume to the PTV

Volume to the PTV

dose

Receiving 20

Volume (100% iso

Volume, R50%

prescribed) at

Gy Total or

2 cm from

More, V20(%)

vol/PTV vol)

PTV in Any
Direction, D2cm
21.3 (LUL)

24.3/21.3=1.14(<1.2 108.4/21.3=5.09(<5.5- 58.1<63-minor

12.1<15-minor

no deviation)

deviation

minor deviation)

deviation)

11.1 (RUL)

14/11.1=1.26(<1.5- 63/11.1=5.68(<5.856.1<58-minor 4.4<10-no

minor deviation)
minor deviation)
deviation
deviation
Table 1. Conformality of Prescribed Dose for Calculations Based on Deposition of Photon Beam
Energy in Heterogeneous Tissue

Organs at Risk

Plan sum (cGy)

Constraints (Gy)

Left Lung

V20=12.1

V20<15 - Met

Right Lung

V20=4.4

V20<15 - Met

Both Lungs
V20=7.9
Spinal Cord
930.9 Max Dose
Heart
V40=0
Esophagus
Mean dose 201.6 cGy
Table 2. Dose Constraints for the Organs at Risk.

V20<15 - Met
Max Dose < 45 Gy - Met
V4030 - Met
Mean dose < 34 Gy - Met