A 3D-conformal technique is better than IMRT or VMAT for lung SBRT

Jing Cai, Harish K. Malhotra, and Colin G. Orton

Citation: Medical Physics 41, 040601 (2014); doi: 10.1118/1.4856175

View online: http://dx.doi.org/10.1118/1.4856175
View Table of Contents: http://scitation.aip.org/content/aapm/journal/medphys/41/4?ver=pdfcov
Published by the American Association of Physicists in Medicine
POINT/COUNTERPOINT
Suggestions for topics suitable for these Point/Counterpoint debates should be addressed to Colin G. Orton, Professor
Emeritus, Wayne State University, Detroit: ortonc@comcast.net. Persons participating in Point/Counterpoint discussions are
selected for their knowledge and communicative skill. Their positions for or against a proposition may or may not reflect their
personal opinions or the positions of their employers.

A 3D-conformal technique is better than IMRT or VMAT for lung SBRT

Jing Cai, Ph.D.
Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina 27710
(Tel: 434-982-0161; E-mail: jing.cai@duke.edu)
Harish K. Malhotra, Ph.D.
Department of Radiation Medicine, Roswell Park Cancer Institute, Buffalo, New York 14263
(Tel: 716-845-1475; E-mail: Harish.Malhotra@Roswellpark.org)

Colin G. Orton, Ph.D., Moderator

(Received 9 December 2013; accepted for publication 9 December 2013; published 4 March 2014)
[http://dx.doi.org/10.1118/1.4856175]

OVERVIEW Arguing against the Propo-

sition is Harish K. Malhotra,
Most clinical studies of stereotactic body radiation therapy
Ph.D. Dr. Malhotra joined the
(SBRT) for the treatment of lung cancers have employed 3D
faculty of Roswell Park Can-
conformal radiotherapy (3DCRT) techniques. Recently, how-
cer Institute (RPCI) in 2002
ever, there has been a trend toward using the more technologi-
and is a Senior Physicist in
cally advanced intensity modulated radiation therapy (IMRT)
the Department of Radiation
or volumetrically modulated arc therapy (VMAT) for these
Medicine. He serves as Assis-
treatments. Some claim, however, that 3DCRT is better than
tant Professor in the Depart-
IMRT or VMAT for lung SBRT, and this is the premise de-
ment of Molecular and Cellular
bated in this month’s Point/Counterpoint.
Biophysics in RPCI’s Graduate
Division of the State Univer-
sity of New York. Dr. Malhotra
Arguing for the Proposi- earned his doctorate in physics from the University of Mum-
tion is Jing Cai, Ph.D. Dr. bai, India, and completed a post-doctoral fellowship in Med-
Cai obtained his Ph.D. de- ical Physics at Montefiore Medical Center, Albert Einstein
gree in Engineering Physics College of Medicine, New York. He is certified in Therapeu-
in 2006 from the University tic Radiologic Physics by the American Board of Radiology
of Virginia where he subse- and is licensed by the State of New York to practice Thera-
quently completed a one-year peutic Medical Physics. Dr. Malhotra is a Section Editor of
Postdoctoral Fellowship and a the Journal of Applied Clinical Medical Physics, has served
two-year Medical Physics Res- on the Board of Chancellors of the ACMP and as President
idency. He moved to Duke Uni- of the Upstate New York Chapter of the AAPM. He has pub-
versity Medical Center in 2009, lished about 30 papers in refereed journals and has been the
where he is currently an Asso- major advisor to five M.S. students.
ciate Professor in the Depart-
ment Radiation Oncology. He is certified in Therapeutic
Radiologic Physics by the American Board of Radiology. FOR THE PROPOSITION: Jing Cai, Ph.D.
Dr. Cai’s major research interests include image-guided
Opening Statement
radiation therapy, 4D imaging and planning, stereotactic-
body radiotherapy, brachytherapy, and MRI. He has Recently there has been an increase in use of IMRT and
published over 40 papers on these topics and regu- VMAT to treat SBRT of the lung. Comparison treatment plan-
larly provides scientific reviews for peer-reviewed jour- ning studies have shown that IMRT and VMAT usually result
nals, scientific conferences, and grant applications. His in more critical structure sparing than 3DCRT.1, 2 However,
research has received federal, charitable, and industrial lung SBRT is a complex treatment, involving multiple steps
funding. (imaging, planning, delivery, and quality assurance of each

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step) with multiple layers of uncertainties. Debating the rel- optimal plan. The skill and experience of the planner played
ative merits and drawbacks of different techniques for lung an important role in such 3DCRT planning.
SBRT should take into account every aspect of the process. A The turning point in the evolution of modern radiation ther-
good technique not only generates good plans but also de- apy came in the 1990s with the advent of IMRT. The synergy
livers them without deviations. 3DCRT has unique advan- of an inverse optimization engine, better dose computation al-
tages over IMRT and VMAT in this regard. First, 3DCRT gorithms, linear accelerators supporting precise dynamic mo-
is not susceptible to the interplay effect between MLC leaf tions, and the ability to target the tumor better with image
motion and tumor respiratory motion. Similarly, compared to guided radiation therapy (IGRT), etc., significantly boosted
IMRT and VMAT 3DCRT is less affected by patient move- technical abilities. The optimization engine has been much
ment during treatment, MLC positioning errors, and the lim- more forgiving (number of beams and their spatial orienta-
ited accuracy of MLC modeling in treatment planning sys- tion) and searched for global minima, thereby producing con-
tems. 3DCRT therefore is expected to have a better agree- sistently better plans. VMAT further improved work flow effi-
ment in target coverage between the plan and delivered treat- ciency by ensuring that the entire treatment could be delivered
ment than IMRT and VMAT, especially when there is large in 1–2 arcs.
respiratory tumor motion or significant modulation in IMRT Recently, lung SBRT has shown excellent local control.8
or VMAT. Second, 3DCRT allows for cine MV imaging dur- In the past, SBRT has most often been delivered using
ing treatment delivery. These images not only verify tumor 3DCRT. Though SBRT in general has been well tolerated,
position in real-time during beam-on, but also provide infor- Fakiris et al.9 reported 17% grade 3–5 toxicities, while
mation that can be used for determining the true 4D dose Timmerman et al.8 reported 12.7% grade 3 toxicities. There
delivered to the tumor3 and for developing more effective are also reported cases of rib fractures.10 Many 3DCRT
lung SBRT treatments, such as tumor trailing,4 probability- plans have dosimetric minor deviations which could be im-
based treatment planning,5 and adaptive radiation therapy.6 proved with IMRT/VMAT. In a recent study, IMRT/VMAT
Cine MV imaging is not applicable to IMRT or VMAT since plans were shown to consistently outperform their respec-
the moving MLC leaves block the majority of the beam tive 3DCRT plans in almost every dosimetric aspect.11 SBRT
view. for advanced central lung cancers requiring nodal irradiation
Furthermore, in our current health care environment where along with primary disease is also being attempted.12 In our
cost is increasingly important, cost-effectiveness needs to preliminary experience, this requires treating complex geo-
be taken into consideration when selecting the technique. graphically separated volumes requiring different simultane-
3DCRT is less expensive than IMRT and VMAT. ous prescription doses for the primary and nodal beds that can
Obviously not all lung SBRT cases are best treated with be handled better with IMRT/VMAT.
3DCRT. Lung tumors vary in location, size, motion, and There is concern that in the absence of any synchroniza-
grade. Some may be more effectively treated using a specific tion between a moving tumor and dynamic motions inherent
modality than others. Nevertheless, institutional experiences in IMRT/VMAT techniques, there may be significant under-
at Duke University Medical Center suggest that the majority dosage of portions of the tumor volume. In ten patients, Rao
of lung SBRT cases (∼70%) can be treated effectively with et al.13 found that both VMAT and IMRT plans experienced a
3DCRT.7 IMRT and VMAT are used only for carefully se- negligible MLC interplay effect with a 400 MU/min repetition
lected patients with large tumor size, small tumor motion, or rate. Similarly, two arcs and ≥2 fractions have been shown
whose dose sparing cannot be achieved with 3DCRT due to to reduce the MLC interplay effect to an apparently clinically
the proximity of critical structures. insignificant level for FFF beams.1 If respiratory gating is em-
ASTRO recently initiated its national Choosing Wisely ployed or a simple abdominal compression is used to dampen
campaign to question the use of treatments that are commonly the tumor motion, the results are expected to be even better.
ordered but may not always be appropriate. In echo with this Whilst it is possible to generate an acceptable SBRT plan
initiative, I conclude my opening statement by recommending for peripheral lung tumors using 3DCRT, it becomes much
that one should not routinely use IMRT or VMAT for lung more challenging for central lung tumors, including advanced
SBRT without considering 3DCRT. tumors, because of the close proximity of critical structures,
which can be better handled consistently with IMRT/VMAT.
If low dose to large volumes of normal tissues is not of clinical
AGAINST THE PROPOSITION: concern, VMAT can even deliver it quickly making the proce-
Harish K. Malhotra, Ph.D. dure better tolerable to the patient, with reduced intrafraction
motion, and less loss of biological effect due to prolonged
Opening Statement
fraction delivery.14 Improvement in work flow efficiency and
The arrival of 3DCRT into mainstream clinics in the 1980s optimal use of departmental resources is the icing on the cake.
was an important milestone in the evolution of radiation ther-
apy. Parameters like number of fields and their spatial ori-
Rebuttal: Jing Cai, Ph.D.
entation with respect to tumor and organs at risk, and lim-
ited beam modulation options (beam energy, weight, wedges, My opponent argues in favor of IMRT/VMAT mainly
blocks, etc.), were iteratively adjusted to get a clinically ac- from three perspectives: plan quality, planning ability, and
ceptable treatment plan but one which may not have been the work flow efficiency. First, I agree that IMRT/VMAT usually

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exhibits a dosimetric advantage over 3DCRT, especially when tion that cine MV-imaging data may pave the way for a better
the target volume is geographically complex or is in close delivery?
proximity to critical structures. In the majority of lung SBRT That 3DCRT for SBRT is inexpensive is a myth. IGRT
cases, however, the target volume has a simple geometry and requirements for SBRT (Ref. 16) require higher-end linacs
3DCRT can generate plans that are clinically equivalent to which have IMRT and/or VMAT capabilities anyway. Slow
those with IMRT/VMAT. Any slight dosimetric advantages 3DCRT delivery represents underutilization of resources, af-
of IMRT/VMAT will be diminished in practice due to various fects throughput and hence possible revenue. If the total cost
uncertainties. of treatment delivery is calculated including the time com-
Regarding planning ability, my opponent argues that skill mitment of staff-members (physician, physicist, therapists),
and experience of the planner play an important role in 3DCRT might be the costliest.
3DCRT planning, while IMRT/VMAT produces consistently Eventually, everything boils down to clinical results. In a
better plans using inverse optimization. Although this is gen- recent study comparing early results for 132 nonsmall-cell
erally true, it should not matter for lung SBRT since the plan- lung patients (86-3DCRT, 46-VMAT), the one-year local con-
ning is relatively simple due to the small target volume and the trol rates for VMAT (100%) and 3DCRT (92.5%), favored
simple geometrical relationship between target volume and VMAT (p = 0.03).17 These statistically significant results
critical structures. Furthermore, IMRT/VMAT planning has demonstrate robustness of the IMRT/VMAT dose delivery
its own challenges, such as limited beam arrangements and chain and should allay my opponent’s concerns. I wholeheart-
couch angles for VMAT in noncoplanar planning, and inter- edly support research initiatives but without sacrificing better
play effects for large tumor motion and the high dose rate for IMRT/VMAT plans. Our patients deserve the best modality
FFF beams. currently available.
Finally, I want to address the issue of work flow efficiency.
IMRT/VMAT requires patient-specific QA, demanding sub-
stantial time for preparation, delivery, and documentation. In 1 C. Ong, W. Verbakel, J. Cuijpers, B. J. Slotman, F. J. Lanerwaard, and
addition, image verification contributes significantly to the S. Senan, “Stereotactic radiotherapy for peripheral lung tumors: A compar-
ison of volumetric modulated arc therapy with 3 other delivery techniques,”
overall treatment time. 3DCRT allows for real-time verifica-
Radiother. Oncol. 97, 437–442 (2010).
tion using cine MV imaging during beam on, thus eliminating 2 G. G. Zhang, L. Ku, T. J. Dilling, C. W. Stevens, R. R. Zhang, W. Li, and

the need for pre- and post-treatment image verification that V. Feygelman, “Volumetric modulated arc planning for lung stereotactic
are usually required in IMRT/VMAT. Furthermore, the high body radiotherapy using conventional and unflattened photon beams,” Ra-
diat. Oncol. 6, 152 (6 pages) (2011) [available URL: http://www.ncbi.nlm.
dose rate with FFF beams (1400 or 2400 MU/min) can im- nih.gov/pmc/articles/PMC3354344/pdf/1748–717X-6–152.pdf].
prove delivery efficiency for 3DCRT but not much for VMAT, 3 G. Li, P. Cohen, H. Xie, D. Low, D. Li, and A. Rimner, “A novel four-

for which treatment delivery time is largely limited by the dimensional radiotherapy planning strategy from a tumor-tracking beam’s
gantry rotation speed.2 eye view,” Phys. Med. Biol. 57, 7579–7598 (2012).
4 D. McQuaid and T. Bortfeld, “4D planning over the full course of fraction-

ation: assessment of the benefit of tumor trailing,” Phys. Med. Biol. 56,
6935–6949 (2011).
Rebuttal: Harish K. Malhotra, Ph.D. 5 F. Zhang, J. Hu, C. R. Kelsey, D. Yoo, F. F. Yin, and J. Cai, “Reproducibil-

My opponent agrees with me that IMRT/VMAT SBRT ity of tumor motion probability distribution function in stereotactic body
radiation therapy of lung cancer,” Int. J. Radiat. Oncol., Biol., Phys. 84,
plans are dosimetrically superior. He has concerns, how- 861–866 (2012).
ever, about their suboptimal delivery and robustness but has 6 Y. Ueda, M. Miyazaki, K. Nishiyama, O. Suzuki, K. Tsujii, and K. Miyagi,

not supported this with any literature. Modern linacs are “Craniocaudal safety margin calculation based on interfractional changes
in tumor motion in lung SBRT assessed with an EPID in cine mode,” J.
pretty reliable15 and are well modeled in treatment planning
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10 N. Pettersson, J. Nyman, and K. A. Johansson, “Radiation-induced rib
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neous kV-imaging, radiofrequency tracking, etc.). Manufac- of VMAT for the treatment of non-small cell lung cancer,” J. Appl. Clin.
Med. Phys. 14(1), 228–238 (2013).
turers usually cap MV-imaging to 100 MU/min, which in- 12 A. Singh, “A pilot study of stereotactic body radiation therapy (SBRT) after
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tients access to better IMRT/VMAT plans with the justifica- IRB approved protocol, Roswell Park Cancer Institute, 2013.

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13 M. Rao, J. Wu, D. Cao, T. Wong, V. Mehta, D. Shepard, and J. Ye, “Dosi- trajectory log files for radiation therapy delivery verification,” Pract. Ra-
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