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      mARC preoperative rectal cancer treatments vs. 3D conformal radiotherapy. A dose distribution comparative study

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      Author(s): 1 , * , 2
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      Publication date (Electronic):
      Journal: PLoS ONE
      Publisher: Public Library of Science

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          Abstract

          Purpose

          mARC (modulated arc) is the arc therapy technique provided by Siemens. The present study analyses the dose distributions and treatment times corresponding to preoperative rectal cancer mARC treatments. The results are compared to those corresponding to 3D-CRT plans.

          Methods

          The plans of 30 patients, each having one mARC and one 3D-CRT plan, were evaluated. Every plan was calculated on a sequential two-phase treatment scheme with prescription doses of 45 Gy in the initial phase and 5.4 Gy in the boost phase. Dosimetric parameters and mean DVHs corresponding to the PTVs and OARs were assessed for both techniques.

          Results

          All mARC plans were considered valid for treatment and yielded a highly significant improvement in the CI over 3D-CRT plans (p <0.001). They also showed statistically significant advantage on the parameters D98%, D95% and D2% of the high dose PTV. Regarding the OARs, mARC plans showed reductions in the mean dose of 3.5 Gy in the bladder and greater than 4 Gy in the femoral heads. Considering the small bowel, the mARC plans resulted in a 2.7 Gy mean reduction in the mean dose and lower irradiated volumes over the entire dose range.

          Conclusions

          Arc therapy plans with the mARC technique for preoperative rectal cancer treatment in a sequential two-phase treatment scheme provide important advantages in the PTVs and OARs. mARC plans show superior protection of the femoral heads, bladder and small bowel, similar to the results found with other more widespread arc therapy techniques.

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          Preoperative versus postoperative chemoradiotherapy for locally advanced rectal cancer: results of the German CAO/ARO/AIO-94 randomized phase III trial after a median follow-up of 11 years.

          Rolf Sauer, Torsten Liersch, Susanne Merkel … (2012)
          Preoperative chemoradiotherapy (CRT) has been established as standard treatment for locally advanced rectal cancer after first results of the CAO/ARO/AIO-94 [Working Group of Surgical Oncology/Working Group of Radiation Oncology/Working Group of Medical Oncology of the Germany Cancer Society] trial, published in 2004, showed an improved local control rate. However, after a median follow-up of 46 months, no survival benefit could be shown. Here, we report long-term results with a median follow-up of 134 months. A total of 823 patients with stage II to III rectal cancer were randomly assigned to preoperative CRT with fluorouracil (FU), total mesorectal excision surgery, and adjuvant FU chemotherapy, or the same schedule of CRT used postoperatively. The study was designed to have 80% power to detect a difference of 10% in 5-year overall survival as the primary end point. Secondary end points included the cumulative incidence of local and distant relapses and disease-free survival. Of 799 eligible patients, 404 were randomly assigned to preoperative and 395 to postoperative CRT. According to intention-to-treat analysis, overall survival at 10 years was 59.6% in the preoperative arm and 59.9% in the postoperative arm (P = .85). The 10-year cumulative incidence of local relapse was 7.1% and 10.1% in the pre- and postoperative arms, respectively (P = .048). No significant differences were detected for 10-year cumulative incidence of distant metastases (29.8% and 29.6%; P = .9) and disease-free survival. There is a persisting significant improvement of pre- versus postoperative CRT on local control; however, there was no effect on overall survival. Integrating more effective systemic treatment into the multimodal therapy has been adopted in the CAO/ARO/AIO-04 trial to possibly reduce distant metastases and improve survival.
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            Volumetric modulated arc therapy: a review of current literature and clinical use in practice.

            M Teoh, C H Clark, K Wood … (2011)
            Volumetric modulated arc therapy (VMAT) is a novel radiation technique, which can achieve highly conformal dose distributions with improved target volume coverage and sparing of normal tissues compared with conventional radiotherapy techniques. VMAT also has the potential to offer additional advantages, such as reduced treatment delivery time compared with conventional static field intensity modulated radiotherapy (IMRT). The clinical worldwide use of VMAT is increasing significantly. Currently the majority of published data on VMAT are limited to planning and feasibility studies, although there is emerging clinical outcome data in several tumour sites. This article aims to discuss the current use of VMAT techniques in practice and review the available data from planning and clinical outcome studies in various tumour sites including prostate, pelvis (lower gastrointestinal, gynaecological), head and neck, thoracic, central nervous system, breast and other tumour sites.
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              Volumetric modulated arc therapy: IMRT in a single gantry arc

              Karl Otto (2008)
              In this work a novel plan optimization platform is presented where treatment is delivered efficiently and accurately in a single dynamically modulated arc. Improvements in patient care achieved through image-guided positioning and plan adaptation have resulted in an increase in overall treatment times. Intensity-modulated radiation therapy (IMRT) has also increased treatment time by requiring a larger number of beam directions, increased monitor units (MU), and, in the case of tomotherapy, a slice-by-slice delivery. In order to maintain a similar level of patient throughput it will be necessary to increase the efficiency of treatment delivery. The solution proposed here is a novel aperture-based algorithm for treatment plan optimization where dose is delivered during a single gantry arc of up to 360 deg. The technique is similar to tomotherapy in that a full 360 deg of beam directions are available for optimization but is fundamentally different in that the entire dose volume is delivered in a single source rotation. The new technique is referred to as volumetric modulated arc therapy (VMAT). Multileaf collimator (MLC) leaf motion and number of MU per degree of gantry rotation is restricted during the optimization so that gantry rotation speed, leaf translation speed, and dose rate maxima do not excessively limit the delivery efficiency. During planning, investigators model continuous gantry motion by a coarse sampling of static gantry positions and fluence maps or MLC aperture shapes. The technique presented here is unique in that gantry and MLC position sampling is progressively increased throughout the optimization. Using the full gantry range will theoretically provide increased flexibility in generating highly conformal treatment plans. In practice, the additional flexibility is somewhat negated by the additional constraints placed on the amount of MLC leaf motion between gantry samples. A series of studies are performed that characterize the relationship between gantry and MLC sampling, dose modeling accuracy, and optimization time. Results show that gantry angle and MLC sample spacing as low as 1 deg and 0.5 cm, respectively, is desirable for accurate dose modeling. It is also shown that reducing the sample spacing dramatically reduces the ability of the optimization to arrive at a solution. The competing benefits of having small and large sample spacing are mutually realized using the progressive sampling technique described here. Preliminary results show that plans generated with VMAT optimization exhibit dose distributions equivalent or superior to static gantry IMRT. Timing studies have shown that the VMAT technique is well suited for on-line verification and adaptation with delivery times that are reduced to approximately 1.5-3 min for a 200 cGy fraction.
              Article 0 comments Cited 185 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                Rocío Bermúdez Luna:
                ORCID: http://orcid.org/0000-0001-7908-0899
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Project administrationRole: ResourcesRole: SupervisionRole: ValidationRole: VisualizationRole: Writing – original draft
                María Victoria de Torres Olombrada: Role: ConceptualizationRole: Data curationRole: ResourcesRole: Writing – review & editing
                Antonio Leal: Role: Editor
                Journal
                Journal ID (nlm-ta): PLoS One
                Journal ID (iso-abbrev): PLoS ONE
                Journal ID (publisher-id): plos
                Journal ID (pmc): plosone
                Title: PLoS ONE
                Publisher: Public Library of Science (San Francisco, CA USA )
                ISSN (Electronic): 1932-6203
                Publication date (Electronic): 16 August 2019
                Publication date Collection: 2019
                Volume: 14
                Issue: 8
                Electronic Location Identifier: e0221262
                Affiliations
                [1 ] Medical Physics Department, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain
                [2 ] Radiation Oncology Department, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain
                University of Seville, SPAIN
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Author information
                http://orcid.org/0000-0001-7908-0899
                Article
                Publisher ID: PONE-D-19-02039
                DOI: 10.1371/journal.pone.0221262
                PMC ID: 6697352
                PubMed ID: 31419263
                SO-VID: 420d92f0-f5fc-4123-b5e7-0b372d0f216e
                Copyright © © 2019 Bermúdez Luna, de Torres Olombrada
                License:

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                Date received : 29 January 2019
                Date accepted : 4 August 2019
                Page count
                Figures: 3, Tables: 7, Pages: 16
                Funding
                The authors received no specific funding for this work.
                Categories
                Subject: Research Article
                Subject: Medicine and Health Sciences
                Subject: Oncology
                Subject: Cancer Treatment
                Subject: Medicine and Health Sciences
                Subject: Oncology
                Subject: Cancers and Neoplasms
                Subject: Gastrointestinal Tumors
                Subject: Rectal Cancer
                Subject: Biology and Life Sciences
                Subject: Anatomy
                Subject: Renal System
                Subject: Bladder
                Subject: Medicine and Health Sciences
                Subject: Anatomy
                Subject: Renal System
                Subject: Bladder
                Subject: Medicine and Health Sciences
                Subject: Oncology
                Subject: Cancer Treatment
                Subject: Radiation Therapy
                Subject: Medicine and Health Sciences
                Subject: Clinical Medicine
                Subject: Clinical Oncology
                Subject: Radiation Therapy
                Subject: Medicine and Health Sciences
                Subject: Oncology
                Subject: Clinical Oncology
                Subject: Radiation Therapy
                Subject: Medicine and Health Sciences
                Subject: Infectious Diseases
                Subject: Infectious Disease Control
                Subject: Vaccines
                Subject: Booster Doses
                Subject: Biology and Life Sciences
                Subject: Toxicology
                Subject: Toxicity
                Subject: Medicine and Health Sciences
                Subject: Pathology and Laboratory Medicine
                Subject: Toxicology
                Subject: Toxicity
                Subject: Medicine and Health Sciences
                Subject: Oncology
                Subject: Biology and Life Sciences
                Subject: Anatomy
                Subject: Exocrine Glands
                Subject: Prostate Gland
                Subject: Medicine and Health Sciences
                Subject: Anatomy
                Subject: Exocrine Glands
                Subject: Prostate Gland
                Custom metadata
                Data Availability All relevant data are within the manuscript and its Supporting Information files.

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