Volumetric-modulated arc therapy vs c-IMRT in esophageal cancer: A treatment planning comparison

doi:10.3748/wjg.v18.i37.5266

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World Journal of Gastroenterology

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1007-9327

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

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World J Gastroenterol. Oct 7, 2012; 18(37): 5266-5275
Published online Oct 7, 2012. doi: 10.3748/wjg.v18.i37.5266

Table 1 Characteristics of patients (n = 20)

Variables	n
Gender
Male	16
Female	4
Age range (yr)	45-82
Stage¹
II	5
III	10
IV	5
Histology
Squamous carcinoma	18
Adenocarcinoma	2

¹According to the American Joint Committee on Cancer 2006 Guidelines.

Table 2 Parameters used in normal tissue complication probability

Organ	Size factor (n)	Slope (m)	TD5/5 (Gy)	TD50/5 (Gy)	End point
Lung	0.87	0.18	17.5	24.5	Pneumonitis
Heart	0.35	0.10	40	48	Pericarditis
Spinal cord	0.05	0.175	47	66.5	Myelitis/necrosis

TD5/5: Tolerance dose leading to 5% complication rates at 5 years; TD50/5: Tolerance dose leading to 50% complication rates at 5 years.

Table 3 Dosimetric results for planning target volume and monitor units

Variable	IMRT-5F	IMRT-7F	IMRT-9F	VMAT-1A	VMAT-2A	P < 0.05
D_mean
Cervical	63.68 ± 0.37	63.07 ± 0.36	62.55 ± 0.39	63.97 ± 0.08	63.63 ± 0.49	2A vs 7F and 9F
Upper	63.30 ± 0.66	62.74 ± 0.49	62.38 ± 0.34	63.90 ± 0.45	63.43 ± 0.63	1A, 2A vs 7F and 9F
Middle	64.12 ± 1.03	64.05 ± 1.27	63.88 ± 1.27	64.83 ± 1.06	64.21 ± 0.59	1A vs 5F and 9F
Lower	63.14 ± 0.90	63.20 ± 1.09	62.98 ± 0.87	64.17 ± 1.26	63.98 ± 1.36	1A vs 5F, 7F and 9F
HI
Cervical	1.10 ± 0.01	1.09 ± 0.01	1.07 ± 0.01	1.11 ± 0.00	1.10 ± 0.01	1A, 2A vs 7F and 9F
Upper	1.09 ± 0.02	1.08 ± 0.01	1.07 ± 0.01	1.10 ± 0.01	1.09 ± 0.02	1A vs 7F and 9F; 2A vs 9F
Middle	1.11 ± 0.02	1.11 ± 0.03	1.11 ± 0.03	1.12 ± 0.02	1.11 ± 0.01	1A vs 9F
Lower	1.09 ± 0.02	1.09 ± 0.03	1.09 ± 0.02	1.11 ± 0.04	1.11 ± 0.03	1A vs 9F
CI
Cervical	0.63 ± 0.03	0.66 ± 0.02	0.74 ± 0.04	0.78 ± 0.03	0.80 ± 0.03	2A vs 5F, 7F, 9F and 1A
Upper	0.62 ± 0.04	0.66 ± 0.03	0.73 ± 0.02	0.79 ± 0.03	0.80 ± 0.02	1A, 2A vs 5F, 7F and 9F
Middle	0.62 ± 0.09	0.67 ± 0.08	0.71 ± 0.10	0.76 ± 0.05	0.74 ± 0.08	1A, 2A vs 5F and 7F
Lower	0.64 ± 0.05	0.67 ± 0.05	0.71 ± 0.05	0.76 ± 0.05	0.77 ± 0.04	1A, 2A vs 5F and 7F
MU
Cervical	1088 (921-1157)	1261 (1094-1393)	1236 (1004-1413)	610 (546 -665)	525 (452-590)	2A vs 5F, 7F, 9F and 1A
Upper	1110 (841-1244)	1251 (950-1377)	1334 (1040-1592)	679 (538-825)	682 (475-1004)	1A, 2A vs 5F, 7F and 9F
Middle	831 (707-980)	903 (808-1086)	999 (858-1219)	418 (347-459)	431 (376-503)	1A, 2A vs 5F, 7F and 9F
Lower	826 (721-966)	923 (720-1234)	1086 (958-1375)	440 (387-540)	419 (347-531)	1A , 2A vs 5F, 7F and 9F

IMRT: Intensity modulated radiotherapy; VMAT: Volumetric modulated arc therapy; F: Coplanar field; A: Arc; HI: Homogeneity index; CI: Conformity index; D_mean: Mean dose; MU: Monitor units.

Table 4 Dosimetric comparison for organs at risk of conventional sliding window intensity-modulated radiotherapy and volumetric-modulated arc therapy in cervical and upper thoracic esophageal cancer, and in middle and lower thoracic esophageal cancer, mean value (range)

Organ	Variable	c-IMRT (5F, 7F, 9F)	VMAT (1A, 2A)	Relative reduction (%)	P < 0.05
In cervical and upper thoracic
Lung (Gy)	MLD¹	12.65 (12.38-13.04)	12.57 (12.35-12.79)	0.6	2A vs 7F, 9F; 1A vs 7F
	MLD²	14.35 (13.91-14.76)	13.94 (13.74-14.14)	2.9	2A vs 7F, 9F
	V5¹	48.52 (46.28-50.52)	51.20 (51.03-51.37)	-5.5	1A, 2A vs 5F, 7F
	V5²	61.53 (57.51-65.06)	66.25 (66.07-66.43)	-7.7	1A , 2A vs 5F, 7F
	V10¹	39.30 (37.41-41.58)	43.44 (43.23-43.65)	-10.5	1A , 2A vs 5F, 7F; 2A vs 9F
	V10²	48.17 (44.18-52.07)	54.25 (53.70-54.79)	-12.6	1A , 2A vs 5F, 7F, 9F
	V20¹	24.70 (23.93-25.16)	24.17 (23.08-25.26)	2.1	1A vs 5F
	V20²	25.58 (24.29-26.23)	22.85 (21.94-23.76)	10.7	NS
	V30¹	14.96 (14.42-15.33)	12.99 (12.99-12.99)	13.2	1A, 2A vs 5F, 7F, 9F
	V30²	14.52 (14.27-15.00)	12.01 (11.58-12.04)	17.3	1A, 2A vs 5F, 7F; 2A vs 9F
Heart (%)	V30¹	6.83 (5.7-7.41)	5.30 (4.57-5.62)	22.4	NS
	V30²	15.20 (13.62-16.96)	10.11 (9.98-10.24)	33.5	1A vs 7F, 9F, 2A
	V40¹	4.33 (3.55-5.08)	2.68 (2.45-2.91)	38.1	NS
	V40²	8.32 (7.00-10.33)	5.30 (5.08-5.22)	36	1A vs 5F, 7F, 9F; 2A vs 5F
	V50¹	2.62 (2.07-3.09)	1.44 (1.43-1.45)	45	NS
	V50²	4.33 (3.44-5.53)	2.63 (2.59-2.67)	39.3	NS
Spinal cord (Gy)	D_max¹	37.92 (37.53-38.32)	37.74 (37.31-38.17)	0.5	NS
	D_max²	37.85 (37.41-38.43)	38.41 (38.05-38.76)	-1.5	NS
Head of humerus	D_max¹	10.00 (5.97-17.59)	21.88 (20.80-22.95)	-118.8	1A , 2A vs 5F, 7F, 9F
(Gy)	D_max²	7.57 (6.47-9.61)	26.44 (26.35-26.52)	-249.3	1A , 2A vs 5F, 7F
	D_mean¹	3.24 (2.07-4.71)	12.27 (11.85-12.69)	-278.7	2A vs 5F, 7F, 9F, 1A
	D_mean²	2.89 (1.47-4.86)	15.26 (14.61-15.90)	-428	2A vs 5F, 7F, 9F, 1A
In middle and lower thoracic
Lung (Gy)	MLD³	15.03 (14.86-15.27)	15.38 (15.24-15.51)	-2.3	1A, 2A vs 5F, 7F
	MLD⁴	15.37 (15.01-15.81)	15.67 (15.51-15.82)	-2	1A vs 5F
	V5³	74.86 (71.00-79.05)	82.83 (82.72-82.93)	-10.6	1A, 2A vs 5F, 7F, 9F
	V5⁴	79.36 (72.43-85.85)	89.91 (89.77-90.04)	-13.3	1A, 2A vs 5F, 7F, 9F
	V10³	55.14 (52.64-58.66)	65.26 (64.75-65.76)	-18.4	1A, 2A vs 5F, 7F, 9F
	V10⁴	59.56 (54.27-64.76)	72.54 (72.04-73.03)	-21.8	1A, 2A vs 5F, 7F; 2A vs 9F
	V20³	24.39 (23.84-24.96)	23.05 (22.28-23.81)	5.5	2A vs 7F, 9F, 1A
	V20⁴	25.32 (24.48-26.66)	21.40 (20.69-22.11)	15.5	1A, 2A vs 5F
	V30³	12.64 (12.08-13.01)	10.97 (10.88-11.06)	13.2	1A,2A vs 5F, 7F; 2A vs 9F
	V30⁴	11.13 (10.55-12.20)	9.10 (8.58-9.62)	18.2	1A, 2A vs 5F, 7F; 2A vs 9F
Heart (%)	V30³	47.30 (46.61-48.20)	42.26 (40.72-43.79)	10.7	1A vs 5F, 7F, 9F
	V30⁴	72.16 (67.81-78.60)	56.55 (55.52-57.57)	21.6	1A vs 5F, 7F, 9F; 2A vs 5F
	V40³	26.89 (24.86-28.14)	22.84 (20.98-24.69)	15.1	1A vs 7F
	V40⁴	33.53 (30.63-38.19)	26.27 (26.21-26.32)	21.7	2A vs 5F
	V50³	14.06 (12.50-16.06)	9.89 (8.93-10.85)	29.7	1A vs 5F, 7F, 9F
	V50⁴	17.99 (14.48-22.87)	11.16 (10.93-11.39)	38	1A, 2A vs 5F; 2A vs 7F, 9F
Spinal cord (Gy)	D_max³	39.03 (38.91-39.15)	38.70 (38.54-38.86)	0.8	NS
	D_max⁴	37.61 (37.45-37.91)	37.99 (37.78-38.20)	-1	NS

Wilcoxon’s signed ranks test.

¹Cervical thoracic esophageal cancer;

²upper thoracic esophageal cancer;

³middle thoracic esophageal cancer;

⁴lower thoracic esophageal cancer. c-IMRT: Conventional sliding window intensity-modulated radiotherapy; VMAT: Volumetric-modulated arc therapy; MLD: Mean dose of lungs; D_max: Maximal dose; D_mean: Mean dose; F: Coplanar field; A: Arc; V_X: The percentage of organ receiving a dose > X Gy; NS: Not significant.

Table 5 Normal tissue complication probability results for organs at risk

Organ	IMRT-5F	IMRT-7F	IMRT-9F	VMAT-1A	VMAT-2A	P < 0.05
Lung
Cervical	0.24 ± 0.14	0.24 ± 0.15	0.32 ± 0.22	0.22 ± 0.18	0.13 ± 0.09	1A vs 9F; 2A vs 5F, 7F, 9F
Upper	0.73 ± 0.62	0.77 ± 0.66	0.84 ± 0.71	0.41 ± 0.37	0.30 ± 0.23	1A vs 7F, 9F; 2A vs 5F, 7F, 9F
Middle	0.62 ± 0.48	0.59 ± 0.48	0.60 ± 0.47	0.57 ± 0.45	0.50 ± 0.41	2A vs 5F
Lower	0.59 ± 0.45	0.59 ± 0.50	0.67 ± 0.46	0.57 ± 0.54	0.46 ± 0.37	2A vs 5F
Heart
Cervical	0	0	0	0	0	NS
Upper	0.02 (0-0.12)	0.02 (0-0.09)	0 (0-0.02)	0	0	NS
Middle	0.61 (0.05-1.07)	0.94 (0.01-4.24)	0.31 (0.01-1.17)	0.13 (0-0.58)	0.21 (0-0.80)	1A vs 5F, 7F, 9F
Lower	6.66 (1.14-16.04)	1.97 (0.11-5.09)	1.76 (0.07-5.95)	1.32 (0-5.81)	0.66 (0-1.59)	1A vs 5F, 9F; 2A vs 5F, 7F, 9F
Spinal cord
Cervical	0	0	0	0	0	NS
Upper	0	0	0	0	0	NS
Middle	0.002 (0-0.01)	0.006 (0-0.03)	0.008 (0-0.04)	0	0	NS
Lower	0	0	0	0	0	NS

IMRT: Intensity-modulated radiotherapy; VMAT: Volumetric modulated arc therapy; F: Coplanar field; A: Arc; NS: Not significant.

Citation: Yin L, Wu H, Gong J, Geng JH, Jiang F, Shi AH, Yu R, Li YH, Han SK, Xu B, Zhu GY. Volumetric-modulated arc therapy vs c-IMRT in esophageal cancer: A treatment planning comparison. World J Gastroenterol 2012; 18(37): 5266-5275
URL: https://www.wjgnet.com/1007-9327/full/v18/i37/5266.htm
DOI: https://dx.doi.org/10.3748/wjg.v18.i37.5266