Robust VMAT treatment planning for extremity soft tissue sarcomas. 2023

Joshua Barrus, and Katelyn Fernando, and Mark Addington, and Nishele Lenards, and Ashley Hunzeker, and David J Konieczkowski
Medical Dosimetry Program, University of Wisconsin, La Crosse, WI, 54601, USA; Wexner Medical Center, The Ohio State University, Columbus, OH, 43210, USA. Electronic address: jwbarrus@gmail.com.

Volumetric modulated arc therapy (VMAT) is a frequently employed and guideline-recommended radiotherapy (RT) modality for extremity soft tissue sarcomas (eSTS). Prior studies have demonstrated that significant tumor volume changes during treatment result in loss of target volume coverage with highly conformal techniques such as VMAT, but few solutions exist to these issues aside from adaptive replanning. Here, we describe a related but novel phenomenon in which relatively minor changes in surface volume contour (whether due to daily setup uncertainty, edema of peritumoral tissue, or progression or pseudo-progression of tumor volume itself) can result in unexpected subcutaneous hotspots. This phenomenon is of significant clinical concern given the known association between skin dose and major wound complications during preoperative RT for eSTS. By evaluating daily cone-beam CT (CBCT) images from thirteen eSTS patients treated with VMAT RT, we identify daily surface contour changes (range: 2 mm-15 mm, median: 8 mm) which are frequently below conventional adaptive replanning thresholds. When applied under experimental conditions, these external contour changes did not have major impacts on target volume coverage (range: 30.2%-91.2%, mean: 72.5%) but did result in unexpected hotspots of 125.8% on average (range: 110.0%-142.2%) in the subcutaneous tissues. To mitigate this issue, we develop a methodology for VMAT treatment planning using flash PTV and virtual bolus (VB) to produce robust treatment plans that are more resistant to target volume changes, surface contour changes, and setup uncertainties than conventional planning methods. With this methodology, robust plans were equivalent to standard plans at baseline, but, after incorporation of surface volume changes, both maintained target volume coverage (p < 0.001) and prevented development of subcutaneous hotspots (p < 0.001) better than standard plans. As such, this treatment planning methodology may facilitate development of robust VMAT treatment plans that minimize development of subcutaneous hotspots and preserve target volume coverage in the context of routine volumetric changes during preoperative RT.

UI MeSH Term Description Entries
D011879 Radiotherapy Dosage The total amount of radiation absorbed by tissues as a result of radiotherapy. Dosage, Radiotherapy,Dosages, Radiotherapy,Radiotherapy Dosages
D011880 Radiotherapy Planning, Computer-Assisted Computer-assisted mathematical calculations of beam angles, intensities of radiation, and duration of irradiation in radiotherapy. Computer-Assisted Radiotherapy Planning,Dosimetry Calculations, Computer-Assisted,Planning, Computer-Assisted Radiotherapy,Calculation, Computer-Assisted Dosimetry,Calculations, Computer-Assisted Dosimetry,Computer Assisted Radiotherapy Planning,Computer-Assisted Dosimetry Calculation,Computer-Assisted Dosimetry Calculations,Dosimetry Calculation, Computer-Assisted,Dosimetry Calculations, Computer Assisted,Planning, Computer Assisted Radiotherapy,Radiotherapy Planning, Computer Assisted
D006801 Humans Members of the species Homo sapiens. Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man
D012509 Sarcoma A connective tissue neoplasm formed by proliferation of mesodermal cells; it is usually highly malignant. Sarcoma, Epithelioid,Sarcoma, Soft Tissue,Sarcoma, Spindle Cell,Epithelioid Sarcoma,Epithelioid Sarcomas,Sarcomas,Sarcomas, Epithelioid,Sarcomas, Soft Tissue,Sarcomas, Spindle Cell,Soft Tissue Sarcoma,Soft Tissue Sarcomas,Spindle Cell Sarcoma,Spindle Cell Sarcomas
D050397 Radiotherapy, Intensity-Modulated CONFORMAL RADIOTHERAPY that combines several intensity-modulated beams to provide improved dose homogeneity and highly conformal dose distributions. Helical Tomotherapy,Intensity-Modulated Arc Therapy,Volumetric-Modulated Arc Therapy,Arc Therapies, Intensity-Modulated,Arc Therapies, Volumetric-Modulated,Arc Therapy, Intensity-Modulated,Arc Therapy, Volumetric-Modulated,Helical Tomotherapies,Intensity Modulated Arc Therapy,Intensity-Modulated Arc Therapies,Intensity-Modulated Radiotherapies,Intensity-Modulated Radiotherapy,Radiotherapies, Intensity-Modulated,Radiotherapy, Intensity Modulated,Therapies, Intensity-Modulated Arc,Therapies, Volumetric-Modulated Arc,Therapy, Intensity-Modulated Arc,Therapy, Volumetric-Modulated Arc,Tomotherapies, Helical,Tomotherapy, Helical,Volumetric Modulated Arc Therapy,Volumetric-Modulated Arc Therapies
D054893 Cone-Beam Computed Tomography Computed tomography modalities which use a cone or pyramid-shaped beam of radiation. CAT Scan, Cone-Beam,Cone-Beam CT,Tomography, Cone-Beam Computed,Tomography, Volume Computed,CT Scan, Cone-Beam,Cone-Beam Computer-Assisted Tomography,Cone-Beam Computerized Tomography,Volume CT,Volume Computed Tomography,Volumetric CT,Volumetric Computed Tomography,CAT Scan, Cone Beam,CAT Scans, Cone-Beam,CT Scan, Cone Beam,CT Scans, Cone-Beam,CT, Cone-Beam,CT, Volume,CT, Volumetric,Computed Tomography, Cone-Beam,Computed Tomography, Volume,Computed Tomography, Volumetric,Computer-Assisted Tomography, Cone-Beam,Computerized Tomography, Cone-Beam,Cone Beam CT,Cone Beam Computed Tomography,Cone Beam Computer Assisted Tomography,Cone Beam Computerized Tomography,Cone-Beam CAT Scan,Cone-Beam CAT Scans,Cone-Beam CT Scan,Cone-Beam CT Scans,Scan, Cone-Beam CAT,Scan, Cone-Beam CT,Scans, Cone-Beam CAT,Scans, Cone-Beam CT,Tomography, Cone Beam Computed,Tomography, Cone-Beam Computer-Assisted,Tomography, Cone-Beam Computerized,Tomography, Volumetric Computed
D058958 Organs at Risk Organs which might be damaged during exposure to a toxin or to some form of therapy. It most frequently refers to healthy organs located in the radiation field during radiation therapy. Organs at Risks,Risk, Organs at,Risks, Organs at,at Risk, Organs,at Risks, Organs

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