Development and evaluation of multiple isocentric volumetric modulated arc therapy technique for craniospinal axis radiotherapy planning

Purpose To develop and compare a volumetric modulated arc therapy (VMAT) technique with conventional radiotherapy for craniospinal irradiation with respect to improved dose conformity and homogeneity in the planning target volume (PTV) and to reduced dose to organs at risk (OAR). Methods and Materials Conventional craniospinal axis radiotherapy plans of 5 patients were acquired. The median (range) length of the PTV was 58.9 (48.1–83.7) cm. The 6-MV VMAT plans were inversely planned with one isocenter near the base of the brain and the minimum number of isocenters required for the specified lengths of spine. The plans were optimized with high weighting for PTV coverage and low weighting for OAR sparing. Conformity and heterogeneity indices, dose–volume histograms, mean doses, and non-PTV integral doses from the two plans (prescription dose 23.4 Gy in 13 fractions) were compared. Results The median (range) conformity index of VMAT was 1.22 (1.09–1.45), compared with 1.69 (1.44–2.67) for conventional plans ( p = 0.04). The median (range) heterogeneity index was also lower for VMAT compared with conventional plans: 1.04 (1.03–1.07) vs. 1.12 (1.09–1.19), respectively ( p = 0.04). A significant reduction of mean and maximum doses was observed in the heart, thyroid, esophagus, optic nerves, and eyes with VMAT when compared with conventional plans. A decrease in body V 10Gy was observed, but for 4 of 5 patients non-PTV integral dose was increased with VMAT when compared with the conventional plans. Conclusions A VMAT technique to treat the craniospinal axis significantly reduces OAR dose, potentially leading to lower late organ toxicity. However, this is achieved at the expense of increased low-dose volumes, which is inherent to the technique, carrying a potentially increased risk of secondary malignancies.