Technical note| Volume 75, P26-32, July 2020

Evaluation of three VMAT-TMI planning methods to find an appropriate balance between plan complexity and the resulting dose distribution


      • Relation of dose distribution and plan complexity is a good tool for plans scoring.
      • MU reduction tool used during VMAT-TMI creation reduce complexity of the plan.
      • Simultaneously optimised 8-arcs with MU reduction is recommended for VMAT-TMI.



      Evaluation of different planning methods of treatment plan preparation for volumetric modulated arc therapy during total marrow irradiation (VMAT-TMI).


      Three different planning methods were evaluated to establish the most appropriate VMAT-TMI technique, based on organ at risk (OAR) dose reduction, conformity and plan simplicity. The methods were: (M1) the sub-plan method, (M2) use of eight arcs optimised simultaneously and (M3) M2 with monitor unit reduction. Friedman ANOVA comparison, with Nemenyi's procedures, was used in the statistical analysis of the results.


      The dosimetric results obtained for the planning target volume and for most OARs do not differ statistically between methods. The M3 method was characterized by the lowest numbers of monitor units (3259 MU vs. 4450 MU for M1 and 4216 MU for M2) and, in general, the lowest complexity. The variability of the monitor units from control points was almost half for M3 than M1 and M2 (i.e. 0.33 MU vs. 0.61 MU for M1 and 0.58 for M2). Analysing the relationship between the dose distributions obtained for the plans and their complexity, the best result was observed for the M3 method.


      The use of eight simultaneously optimised arcs with MU reduction allows to obtain VMAT-TMI plans that are characterized by the lowest complexity, with dose distributions comparable to the plans generated by other methods.


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        • Mancosu P.
        • Cozzi L.
        • Muren L.P.
        Total marrow irradiation for hematopoietic malignancies using volumetric modulated arc therapy: a review of treatment planning studies.
        Phys Imaging Radiat Oncol. 2019; 2019: 47-53
        • Wong J.Y.C.
        • Filippi A.R.
        • Dabaja B.S.
        • Yahalom J.
        • Specht L.
        Total body irradiation: guidelines from the international lymphoma radiation oncology group (ILROG).
        Int J Radiat Oncol Biol Phys. 2018; 101: 521-529
        • Paix A.
        • Antoni D.
        • Waissi W.
        • Ledoux M.P.
        • Bilger K.
        • Fornecker L.
        • et al.
        Total body irradiation in allogeneic bone marrow transplantation conditioning regimens: a review.
        Crit Rev Oncol Hematol. 2018; 123: 138-148
        • Zaucha R.E.
        • Buckner D.C.
        • Barnett T.
        • Holmberg L.A.
        • Gooley T.
        • Hooper H.A.
        • et al.
        Modified total body irradiation as a planned second high-dose therapy with stem cell infusion for patients with bone-based malignancies.
        Int J Radiat Oncol Biol Phys. 2006; 64: 227-234
        • Hartman A.R.
        • Williams S.F.
        • Dillon J.J.
        Survival, disease-free survival and adverse effects of conditioning for allogeneic bone marrow transplantation with busulfan/cyclophosphamide vs total body irradiation: a meta-analysis.
        Bone Marrow Transplant. 1998; 22: 439-443
        • Blaise D.
        • Maraninchi D.
        • Michallet M.
        • Reiffers J.
        • Jouet J.P.
        • Milpied N.
        • et al.
        Long-term follow-up of a randomized trial comparing the combination of cyclophosphamide with total body irradiation or busulfan as conditioning regimen for patients receiving HLA-identical marrow grafts for acute myeloblastic leukemia in first complete remission.
        Blood. 2001; 97: 3669-3671
        • Dusenbery K.E.
        • Daniels K.A.
        • McClure J.S.
        • McGlave P.B.
        • Ramsay N.K.
        • Blazar B.R.
        • et al.
        Randomized comparison of cyclophosphamide-total body irradiation versus busulfan-cyclophosphamide conditioning in autologous bone marrow transplantation for acute myeloid leukemia.
        Int J Radiat Oncol Biol Phys. 1995; 31: 119-128
        • Michel G.
        • Gluckman E.
        • Esperou-Bourdeau H.
        • Reiffers J.
        • Pico J.L.
        • Bordigoni P.
        • et al.
        Allogeneic bone marrow transplantation for children with acute myeloblastic leukemia in first complete remission: impact of conditioning regimen without total-body irradiation–a report from the Societe Francaise de Greffe de Moelle.
        J Clin Oncol. 1994; 12: 1217-1222
        • Bunin N.
        • Aplenc R.
        • Kamani N.
        • Shaw K.
        • Cnaan A.
        • Simms S.
        Randomized trial of busulfan vs total body irradiation containing conditioning regimens for children with acute lymphoblastic leukemia: a Pediatric Blood and Marrow Transplant Consortium study.
        Bone Marrow Transplant. 2003; 32: 543-548
        • Clift R.A.
        • Buckner C.D.
        • Appelbaum F.R.
        • Sullivan K.M.
        • Storb R.
        • Thomas E.D.
        Long-term follow-up of a randomized trial of two irradiation regimens for patients receiving allogeneic marrow transplants during first remission of acute myeloid leukemia.
        Blood. 1998; 92: 1455-1456
        • Ringden O.
        • Ruutu T.
        • Remberger M.
        • Nikoskelainen J.
        • Volin L.
        • Vindelov L.
        • et al.
        A randomized trial comparing busulfan with total body irradiation as conditioning in allogeneic marrow transplant recipients with leukemia: a report from the Nordic Bone Marrow Transplantation Group.
        Blood. 1994; 83: 2723-2730
        • Wolden S.L.
        • Rabinovitch R.A.
        • Bittner N.H.J.
        • Galvin J.M.
        • Giap H.B.
        • Schomberg P.J.
        • et al.
        American College of Radiology (ACR) and American Society for Radiation Oncology (ASTRO) practice guideline for the performance of total body irradiation (TBI).
        J Clin Oncol. 2013; 36: 97-101
        • Bieri S.
        • Helg C.
        • Chapuis B.
        • Miralbell R.
        Total Body Irradiation before allogeneic bone marrow transplantation: is more dose better?.
        Int J Radiat Oncol Biol Phys. 2001; 49: 1071-1077
        • Aristei C.
        • Alessandro M.
        • Santucci A.
        • Aversa F.
        • Tabillo A.
        • Carotti
        • et al.
        Cataracts in patients receiving stem cell transplantation after conditioning with total body irradiation.
        Bone Marrow Transplant. 2002; 29: 503-507
        • Zierhut D.
        • Lohr F.
        • Schraube P.
        • Huber P.
        • Wenz F.
        • Haas R.
        Cataract incidence after total-body irradiation.
        Int J Radiat Oncol Biol Phys. 2000; 46: 131-135
        • Belkacemi Y.
        • Ozsahin M.
        • Pene F.
        • Rio B.
        • Laporte J.P.
        • Leblond V.
        • et al.
        Cataractogenesis after total body irradiation.
        Int J Radiat Oncol Biol Phys. 1996; 35: 53-60
        • Curtis R.E.
        • Rowlings P.A.
        • Deeg H.J.
        • Shriner D.A.
        • Socie G.
        • Travis L.B.
        Solid cancers after bone marrow transplantation.
        N Engl J Med. 1997; 36: 897-904
        • Hasegawa W.
        • Pond G.R.
        • Rifkind J.T.
        • Messner H.A.
        • Lau A.
        • Daly A.S.
        • et al.
        Long-term follow-up of secondary malignancies in adults after allogeneic bone marrow transplantation.
        Bone Marrow Transplant. 2005; 35: 51-55
        • Rizzo J.D.
        • Curtis R.E.
        • Socie G.
        • Sobocinski K.A.
        • Gilbert E.
        • Landgren O.
        • et al.
        Solid cancers after allogeneic hematopoietic cell transplantation.
        Blood. 2009; 113: 1175-1183
        • Witherspoon R.P.
        • Fisher L.D.
        • Schoch G.
        • Martin P.
        • Sullivan K.M.
        • Sanders J.
        • et al.
        Secondary cancers after bone marrow transplantation for leukemia or aplastic anemia.
        N Engl J Med. 1989; 321: 784-789
        • Lawton C.A.
        • Cohen E.
        • Barber-Derus S.
        • Murray K.J.
        • Ash R.C.
        • Casper J.T.
        • et al.
        Late renal dysfunction in adult survivors of bone marrow transplantation.
        Cancer. 1991; 67: 2795-2800<2795::aid-cncr2820671114>;2-d
        • Thomas B.C.
        • Stanhope R.
        • Plowman P.N.
        • Leiper A.D.
        Growth following single fraction and fractionated total body irradiation for bone marrow transplantation.
        Eur J Pediatr. 1993; 152: 888-892
        • Papadimitriou A.
        • Urena M.
        • Hamill G.
        • Stanhope R.
        • Leiper A.D.
        Growth hormone treatment of growth failure secondary to total body irradiation and bone marrow transplantation.
        Arch Dis Child. 1991; 66: 689-692
        • Sanders J.E.
        Endocrine problems in children after bone marrow transplant for hematologic malignancies. The long-term follow-up team.
        Bone Marrow Transplant. 1991; 8: 2-4
        • Carruthers S.A.
        • Wallington M.M.
        Total body irradiation and pneumonitis risk: a review of outcomes.
        Br J Cancer. 2004; 90: 2080-2084
        • Della Volpe A.
        • Ferreri A.J.
        • Annaloro C.
        • Mangili P.
        • Rosso A.
        • Calandrino R.
        • et al.
        Lethal pulmonary complications significantly correlate with individually assessed mean lung dose in patients with hematologic malignancies treated with total body irradiation.
        Int J Radiat Oncol Biol Phys. 2002; 52: 483-488
        • Van Dyk J.
        • Keane T.J.
        • Kan S.
        • Rider W.D.
        • Fryer C.J.
        Radiation pneumonitis following large single dose irradiation: a re-evaluation based on absolute dose to lung.
        Int J Radiat Oncol Biol Phys. 1981; 7: 461-467
        • Girinsky T.
        • Socie G.
        • Ammarguellat H.
        • Cosset J.M.
        • Briot E.
        • Bridier A.
        • et al.
        Consequences of two different doses to the lungs during a single dose of total body irradiation: results of a randomized study on 85 patients.
        Int J Radiat Oncol Biol Phys. 1994; 30: 821-824
        • Pino Y.
        • Torres J.L.
        • Bross D.S.
        • Lam W.C.
        • Wharam M.D.
        • Santos G.W.
        • et al.
        Risk factors in interstitial pneumonitis following allogenic bone marrow transplantation.
        Int J Radiat Oncol Biol Phys. 1982; 8: 1301-1307
        • Clift R.A.
        • Buckner C.D.
        • Appelbaum F.R.
        • Bryant E.
        • Bearman S.I.
        • Petersen F.B.
        • et al.
        Allogeneic marrow transplantation in patients with chronic myeloid leukemia in the chronic phase: a randomized trial of two irradiation regimens.
        Blood. 1991; 77: 1660-1665
        • Hui S.K.
        • Kapatoes J.
        • Flower J.
        • Henderson D.
        • Olivera G.
        • Manon R.R.
        • et al.
        Feasibility study of helical tomotherapy for total body or total marrow irradiation.
        Med Phys. 2005; 32: 3214-3224
        • Aydogan B.
        • Mundt A.J.
        • Roeske J.C.
        Linac-based intensity modulated total marrow irradiation (IM-TMI).
        Technol Cancer Res Treat. 2006; 5: 513-519
        • Wong J.Y.
        • Liu A.
        • Schultheiss T.
        • Popplewell L.
        • Stein A.
        • Rosenthal J.
        • et al.
        Targeted Total Marrow Irradiation using three-dimensional Image-Guided Tomographic Intensity-Modulated Radiation Therapy: an alternative to standard Total Body Irradiation.
        Biol Blood Marrow Transplant. 2006; 12: 306-315
        • Wong J.Y.
        • Rosenthal J.
        • Liu A.
        • Schultheiss T.
        • Forman S.
        • Somlo G.
        Image-guided total marrow irradiation using helical tomotherapy in patients with multiple myeloma and acute leukemia undergoing hematopoietic cell transplantation.
        Int J Radiat Oncol Biol Phys. 2009; 73: 273-279
        • Yeginer M.
        • Roeske J.C.
        • Radosevich J.A.
        • Aydogan B.
        Linear accelerator-based intensity-modulated total marrow irradiation technique for treatment of hematologic malignancies: a dosimetric feasibility study.
        Int J Radiat Oncol Biol Phys. 2011; 79: 1256-1265
        • Fogliata A.
        • Cozzi L.
        • Clivio A.
        • Ibatici A.
        • Mancosu P.
        • Navarria P.
        • et al.
        Preclinical assessment of volumetric modulated arc therapy for total marrow irradiation.
        Int J Radiat Oncol Biol Phys. 2011; 80: 628-636
        • Aydogan B.
        • Yeginer M.
        • Kavak G.O.
        • Fan J.
        • Radosevich J.A.
        • Gwe-Ya K.
        Total marrow irradiation with RapidArc volumetric arc therapy.
        Int J Radiat Oncol Biol Phys. 2011; 81: 592-599
        • Corvo R.
        • Zeverino M.
        • Vagge S.
        • Agostinelli S.
        • Barra S.
        • Taccini G.
        • et al.
        Helical tomotherapy targeting total bone marrow after total body irradiation for patients with relapsed acute leukemia undergoing an allogeneic stem cell transplant.
        Radiother Oncol. 2011; 98: 382-386
        • Jurado-Bruggeman D.
        • Victor Hernández V.
        • Sáez J.
        • Navarro D.
        • Pino F.
        • Martínez T.
        • et al.
        Multi-centre audit of VMAT planning and pre-treatment verification.
        Radiother Oncol. 2017; 124: 302-310
        • Hernandez V.
        • Saez J.
        • Pasler M.
        • Jurado-Bruggeman D.
        • Jornet N.
        Comparison of complexity metrics for multi-institutional evaluations of treatment plans in radiotherapy.
        Phys Im Radiat Oncol. 2018; 5: 37-43
        • Glenn M.C.
        • Hernandez V.
        • Saez J.
        • Followill D.S.
        • Howell R.M.
        • Pollard-Larkin J.M.
        • et al.
        Treatment plan complexity does not predict IROC Houston anthropomorphic head and neck phantom performance.
        Phys Med Biol. 2019; 63205015
        • Crowe S.B.
        • Kairn T.
        • Kenny J.
        • Knight R.T.
        • Hill B.
        • Langton C.M.
        • et al.
        Treatment plan complexity metrics for predicting IMRT pre-treatment quality assurance results.
        Australas Phys Eng Sci Med. 2014; 37: 475-482
        • Park J.M.
        • Park S.
        • Kim H.
        • Kim J.H.
        • Carlson J.
        • Ye S.J.
        Modulation indices for volumetric modulated arc therapy.
        Phys Med Biol. 2014; 59: 7315-7340
        • Masi L.
        • Doro R.
        • Favuzza V.
        • Cipressi S.
        • Livi L.
        Impact of plan parameters on the dosimetric accuracy of volumetric modulated arc therapy.
        Med Phys. 2013; 40071718
      1. International Commission on Radiation Units and Measurements. ICRU report 83: prescribing, recording, and reporting photon beam intensity-modulated radiation therapy (IMRT). J ICRU 2010;10(1).

        • Clemente S.
        • Cozzolino M.
        • Chiumento C.
        • Fiorentino A.
        • Caivano R.
        • Fusco V.
        Monitor unit optimization in RapidArc plans for prostate cancer.
        J Appl Clin Med Phys. 2013; 14: 52-63
        • Prado A.
        • Gaitán Á.
        • Leonor M.
        • Manzano M.
        • Cabello E.
        • Díaz R.
        • et al.
        Performance of the eclipse monitor unit objective tool utilizing volumetric modulated arc therapy for rectal cancer.
        Rep Pract Oncol Radiother. 2019; 24: 227-232
        • Jiménez-Puertas S.
        • Sánchez-Artuñedo D.
        • Hermida-López M.
        Assessment of the Monitor Unit Objective tool for VMAT in the Eclipse treatment planning system.
        Rep Pract Oncol Radiother. 2018; 23: 121-125
        • Surucu M.
        • Yeginer M.
        • Kavak G.O.
        • Fan J.
        • Radosevich J.A.
        • Aydogan B.
        Verification of dose distribution for volumetric modulated arc therapy total marrow irradiation in a humanlike phantom.
        Med Phys. 2012; 39: 281-288
        • Mancosu P.
        • Navarria P.
        • Castgna L.
        • Reggiori G.
        • Sarina B.
        • Tomatis S.
        • et al.
        Interplay effects between dose distribution quality and positioning accuracy in total marrow irradiation with volumetric modulated arc therapy.
        Med Phys. 2013; 40111713
        • Litoborska J.
        • Piotrowski T.
        • Jodda A.
        • Malicki J.
        Evolution of treatment planning and dose delivery methods during radiotherapy for patients undergoing bone marrow transplantation: a review.
        Nukleonika. 2020; 65: 19-30
        • Schultheiss T.E.
        • Wong J.Y.
        • Liu A.
        • Olivera G.
        • Somlo G.
        Image-guided total marrow and total lymphatic irradiation using helical tomotherapy.
        Int J Radiat Oncol Biol Phys. 2007; 67: 1259-1267
        • Symons K.
        • Morrison C.
        • Parry J.
        • Woodings S.
        • Zissiadis Y.
        Volumetric modulated arc therapy for total body irradiation: a feasibility study using Pinnacle3 treatment planning system and Elekta AgilityTM linac.
        J Appl Clin Med Phys. 2018; 19: 103-110
        • Mancosu P.
        • Navarria P.
        • Castagna L.
        • Reggiori G.
        • Stravato A.
        • Gaudino A.
        • et al.
        Plan robustness in field junction region from arcs with different patient orientation in total marrow irradiation with VMAT.
        Phys Med. 2015; 31: 677-682
        • Miften M.
        • Olch A.
        • Mihailidis D.
        • Moran J.
        • Pawlicki T.
        • Molineu A.
        • et al.
        Tolerance limits and methodologies for IMRT measurement-based verification QA: recommendations of AAPM Task Group No. 218.
        Med Phys. 2018; 45: e53-e83