Outline

• Patient History
• Disease, surgery, and systemic therapy
• Planning
• Pre­planning
• Simulation
• Target volumes
• OAR
• Prescription
• Planning Process
• Goals
• Techniques
• Plan results
• Objectives and DVH analysis
• Discussion
 Patient History
• 77 y.o. male
• SCC of Proximal Esophagus
• 24cm from incisors
• T1bNxM0
• Surgery
• Flexible EGD biopsy
• Endoscopic mucosal resection
• Chemotherapy
• Carbo­Taxol
• Radiation Therapy
• Concurrent with Chemotherapy
 Simulation
• Patient position:
• Supine
• Both arms above head
• Immobilization
• Vac­Bag
• Wingboard
• B Headrest
• Large sponge under knees
• Treatment Planning CT Scan
• Shallow breathing
• 2.5 mm slice thickness
Simulation
 Target Volumes
• Gross Tumor Volume
• GTVp1
• 4.9 cm x 2.6 cm
 Target Volumes
• Clinical Target Volume
• GTVp1 → CTV (Magenta) Expansions
• 3 cm Superior and Inferior
• 1 cm Radial
 Target Volumes
• Planning Target Volumes
• PTV_4500 (Green)
• CTV → PTV_4500 Expansion
• 0.5cm in all directions
 Target Volumes
• Planning Target Volumes
• PTV_5000 (Cyan)
• GTVp1 → PTV_5000 Expansion
• 0.5cm in all directions
 Target Volumes

• PTV_4500 (Green)

• PTV_5000 (Cyan)
 Organs at Risk
• Lungs
• Lung window
• Contoured in entirety
• Heart
• Abdomen window
• Along pericardial sac
• Superior limit
• Level of inferior aspect of aortic arch
• Inferior limit
• Apex
• Spinal Cord
• Abdomen window
• Bony limits of spinal canal
• Entire length of CT scan
Organs at Risk

Lungs
Organs at Risk

Heart
Organs at Risk

Spinal Cord
 Prescription

• Simultaneous Integrated Boost:

• PTV_4500
• 180cGy x 25 fractions

• PTV_5000
• 200cGy x 25 fractions
Physician Dose Intent

RTOG 1010
 3D Plan
• 2 separate plans to create SIB:

• Esophagus_3D
• 5 beams conform to PTV_4500

• Esophagus_3DSF
• 5 beams conform to GTVp1

• AcurosXB Algorithm
• Calculation Grid
• 0.25cm
 Esophagus_3D Beams Geometries and Energies

Beam# Energy Gantry(°) Collimator Couch Angle(°)

Angle(°)
1 PA
60° EDW Heel 16MV 180 0 0
Inferior

2 RPO
30° EDW Heel 6MV 220 90 0
Posterior

3 RPO
10° EDW Heel 6MV 265 90 0
Posterior

4 LPO
10° EDW Heel 6MV 95 90 0
Posterior

5 LPO
30° EDW Heel 6MV 140 90 0
Posterior
 3D Plan
Esophagus_3D
Beam geometries and EDW orientation
 3D Plan
Esophagus_3D
Beam geometries and EDW orientation
 Esophagus_3DSF Beams Geometries and 
Energies
Beam# Energy Gantry(°) Collimator Couch Angle(°)
Angle(°)

1A PA
No EDW 16MV 180 0 0

2A RPO
No EDW 16MV 220 0 0

3A RPO
No EDW 16MV 265 0 0

4A LPO
No EDW 16MV 95 0 0

5A LPO
No EDW 16MV 140 0 0
 3D Plan

Esophagus_3DSF
Beam geometries
 3D Plan
1_PA MLC margins
 3D Plan
2_RPO MLC margins
 3D Plan
3_RPO MLC margins
 3D Plan
4_LPO MLC margins
 3D_SF Plan
5_LPO MLC margins
 3D_SF Plan
1A_PA MLC margins
 3D_SF Plan
2A_RPO MLC margins
 3D_SF Plan
3A_RPO MLC margins
 3D_SF Plan
4A_LPO MLC margins
 3D_SF Plan
5A_LPO MLC margins
 Esophagus_3D

• Prescribed to isocenter

• Normalized to 98%IDL

• Hotspot 107.4% of Rx dose (4500cGy)

Esophagus_3D
 Esophagus_3D_SF

• Prescribed to off­axis calculation point

• Normalized to 97%IDL

• Hotspot 119.5% of Rx dose (500cGy)

Esophagus_3D_SF
Combined Esophagus 3D and Esophagus 3D_SF
 VMAT Plan
• 2 full arcs
Simultaneous Integrated Boost:

• PTV_4500
• 180cGy x 25 fractions

• PTV_5000
• 200cGy x 25 fractions

• AcurosXB Algorithm
• Calculation Grid
• 0.25cm
 VMAT Plan
Beam# Energy Gantry Travel(°) Collimator Couch Angle(°)
Angle(°)
1 6MV 181­179 5 0

2 6MV 179­181 45 0
 VMAT Plan Optimization
Separate “Opti” PTV’s

1mm expansion PTV_4500→ Op _45 and PTV_5000→ Op _50

• Opti_45 (green) cropped from Opti_50 (blue) + additional 1mm

• Opti_50 (blue) cropped from GTVp1 (red) + additional 1mm
 VMAT Plan Optimization
Opti Lung created (Pink)

Opti_Lungs cropped from Opti_45 +1mm margin

VMAT Plan Optimization Objectives
VMAT Plan Optimization Objectives
VMAT Plan Optimization NTO
 VMAT Plan
Hotspot 107.1% of Rx dose (5000cGy)
 3D versus VMAT Plan Results

3D SIB VMAT SIB

3D versus VMAT Plan Results
3D

VMAT
3D versus VMAT DVH Comparison

∆ = 3D SIB
□ = VMAT SIB
 Discussion 3D v VMAT
• Comparable plan results

• GTV and PTV’s well covered using both techniques

• VMAT SIB Advantages over 3D SIB:

• Superior OAR sparing
• Particularly Lungs
• Faster delivery time
• 2 arcs v. 10 static fields

• VMAT SIB Disadvantage over 3D SIB:

• Larger integral dose

• Patient was treated with VMAT SIB plan

• No evidence of esophagus cancer 1 ½ years post­RT
Thank You!