AAMD Virtual 46th Annual Meeting 6/6/2021

2021 AAMD Plan Study: Thorax
Sponsored by Elekta

Zachary Fellows, CMD, RT(T)(R)
June 6, 2021

Disclosures

No Financial Disclosures

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Overview
• Why do a Plan Study? Why Thorax?
• Background & Treatment Options
• Clinical Example
• Planning Techniques
• Dose Metrics and Scoring
• Results and Discussion
• Tips and Tricks
• Top Performers

Why do a plan study? Why Thorax?

• Sharing is caring

• Better plans = Better patient outcomes

• Challenging plan regardless of modality 
– Due to location and extent of tumor

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Background & Treatment 
Options

Background: Statistics

• Adenocarcinoma: Subtype of non‐
small cell lung cancer (NSCLC)
• (NSCLC) most common type of 
cancer diagnosed
• Accounts for 40% of all Lung 
Cancers
• Aprox. 25% of patients will have 
locally advance disease at time of 
diagnosis
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Treatment Options

Surgery

Radiation therapy

Chemotherapy

Immunotherapy

Clinical 
Example

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Patient X

• 59yo Male
• 15pack year smoker
• Stage IIIB, cT2bN3M0 Adenocarcinoma of the LLL
• Tumor too large for upfront Chemo+Radiation
• Started 2 cycles of Chemotherapy followed by 2 
cycles of Chemo + Immunotherapy
• Returned for RT

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Difficulties….

• Achieving adequate 
dose for tumor control

• Not exceeding critical 
OARs

• Moving Target

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Dose Fractionation

• 61.2Gy over 34Fx in 1.8Gy/Fx

• 1.8Gy/Fx vs 2Gy/Fx
– decreases late toxicity while maintaining tumor 
control

• 60Gy BED

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Moving Target

• 4DCT
– Larger target volumes i.e. iCTV

• ABC/Breath Hold
– Ideal to limit motion
– Patient dependent
– Increased treatment duration

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Planning
Techniques

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Planning Technique: Photon
Technique: Energy:
Static IMRT 6 MV most utilized

VMAT 10 MV

TomoTherapy 6 and 10 FFF

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Planning Technique: Proton

• Protons can be used in setting of lung 
BUT…

• Beam arrangement!

• Make it Robust

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Planning Technique: Proton

• Robustness: the 
ability to withstand 
or overcome adverse 
conditions or 
rigorous testing 

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Dose Metrics and 
Scoring Criteria

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Dose Metrics

• 25 Key Metrics
– Max Score: 
150pts

• Critical OARs 
in thorax
– Lungs‐GTV
– Esophagus

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Lungs‐GTV

• Critical Constraints
• V20<37
• Mean <20Gy

• Pneumonitis

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Lungs‐GTV: Mean

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Lungs‐GTV: V20

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Esophagus

• V60<17%
– Esophagitis
• Esophagus = 74.8cm3
• Overlap of PTV and 
Esophagus = 15.4cm3
– 20% direct overlap!

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Esophagus:V60

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Most Challenging Metrics

• Lungs‐GTV
– V20, V10, V5
• Esophagus
– V60
• Max doses

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Lungs‐GTV: V5

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Results and Discussion

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Score by Radiation Type

• 202 Photon 
Submissions
• Avg Score:
126.8

• 27 Proton 
Submissions
• Avg Score:
144.8

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Score by 
TPS

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Score by TPS

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Score by TPS

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Score vs. Total MU 
150
140
130
120
110
Plan Score

100
90
80
70
60
50
40
30 MU (IMRT)
20 MU (VMAT)
10
0
0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000
Total Monitor Units

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32 2021 Participation by Country
100
91
90

80

70

60

50

40

30

20 15 15 16
12
7 9
10 5 4 6 4 6 4 5
1 1 1 1 2 1 2 2 1 1 1 1 2 2 1 1 2 1 1 2 1
0
1

Argentina Australia Belarus Belgium Canada China Colombia

Czech Republic France Germany Greece Hong Kong India Israel
Italy Japan Luxembourg Malaysia Morocco Nepal New Zealand
Peru Philippines Portugal Russian Federation Singapore Slovakia Spain
Sweden Switzerland The Netherlands Ukraine United Kingdom United States N/A

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Tips and Tricks

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Planning Structures

• PRVs
• Trim targets off overlapping OARS & 
PRVs
• Convert overlap areas to high resolution 
segments
• Planning Lungs‐GTV:
• Lungs subtracted from PTV plus a margin
• Margin from PTV ranged from 3mm to 
2cm
• Customized planning PTV

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Plan Design: Photons
• Mixed energies • Partial non‐coplanar 
– 6 and 10 MV beams
– FFF  • Offset angles to 
• Optimize collimator  establish control points 
angles between gantry spacing
• Fixed Jaws • Tomo
– Limit and lock jaws – Finding perfect pitch

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Multi‐Iso Technique

• Multiple Isocenters
• Separate Targets; 
– (3) Right superior, middle, and left inferior
• Right Superior‐ Non‐coplanar partial 
arcs
• Middle‐ Narrow, full arc
• Left Inferior‐ Non coplanar partial arcs

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General Optimization
• Establishing an optimization hierarchy
– What is driving the plan?
• Get coverage first then slowly push OARs 
– Iterative process
• Automation
– Mixed utilization
• Use smaller pseudo structures to heat or 
cool
– More effective than optimizing large structures

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Optimization: Protons

• Beam Arrangement
– Use the right tool for the job
• Biological dose objectives
• 4D Robust Optimization
• Minimizing individual beam contribution 
for LLL

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Persistence

• “Enough small improvements may 
eventually add up to a major 
improvement.”

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Top Performers

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List of High Performers
Top Proton Plans (149+ Score): All TPS
Place Participant Name Institution Country TPS Model # Beams Score
1 (tie) Ray Dalfsen Elekta Australia Monaco 6 150.00
1 (tie) Fazal Khan Miami Cancer Institute United States RayStation 4 150.00
1 (tie) Brian Neal New Jersey ProCure United States RayStation 5 150.00
1 (tie) James Henry WK Cancer Center United States RayStation 3 150.00
1 (tie) Xuanfeng Ding Beaumont Health United States RayStation 18 150.00
6 Zachary Fellows Johns Hopkins United States RayStation 5 149.99
7 Nicolas Depauw Massachusetts General Hospital United States Astroid 4 149.92
8 Stephen Zieminski MGH United States Astroid 4 149.82
9 David Littlejohn Varian Medical Systems Las Vegas, NV United States Eclipse 5 149.81
10 Dennie Fransen RaySearch Laboratories The Netherlands RayStation 5 149.68
11 Kevin Greco Moffitt Cancer Center United States RayStation 3 149.45
12 Juan Maria Perez Moreno Quironsalud Protontherapy Center Spain RayStation 7 149.32
13 Laertes Papaspyrou Philips Healthcare Greece Pinnacle3 5 149.08
14 Zamaltdinov Rail FSBI FSCCMRO of FMBA of Russia Russian Federation XiO 4 148.99

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List of High Performers:
Top 10% Photon Plans: All TPS
Place Participant Name Institution Country TPS Model Delivery # Beams Energy (MV) Total MU Score
1 Kwong Tsun Yin Keith St. Teresa's Hospital Hong Kong Eclipse VMAT 14 10FFF 2756 146.01
2 YIK SHING cheung St. Teresa's Hospital Hong Kong Eclipse VMAT 12 10FFF 3013 145.81
3 TSO GARY KA YU St Teresa`s Hospital Hong Kong Eclipse VMAT 18 10FFF 2142 145.77
4 Kai Leung Li St Teresa's Hospital Oncology Centre Hong Kong Eclipse VMAT 14 10FFF 2339 145.13
5 Lee Chun Long St. Teresa's Hospital Hong Kong Eclipse VMAT 15 10FFF 2025 145.07
6 xielunqi China AnShan city cancer hospital China Eclipse IMRT 20 6 4275 143.80
7 zhanyingjie China  China Eclipse IMRT 20 6 4334 143.08
8 Paul Barry Elekta United States Monaco VMAT 8 10 2550 142.89
9 Teresa Chim St. Teresa's Hospital Hong Kong Eclipse VMAT 14 10 + 10FFF 2534 142.66
10 Liqinghao Anshan tumor hospital China Eclipse IMRT 20 6 3858 142.26
11 Mark Bowers Moffitt Cancer Center United States RayStation VMAT 8 6FFF 1641 141.66
12 R. Ngan sheffield hallam university Hong Kong Eclipse VMAT 8 10FFF 2932 141.46
13 JOHN DOOLEY ACCURAY, INC. United States Ring Gantry Helical Arc 16 141.15
14 Richard Braun Accuray Germany Ring Gantry Helical Arc 16 141.13
15 Dalibor Lojko Nemocnica AGEL Komarno s.r.o. Slovakia Eclipse VMAT 6 6FFF 1584 140.48
16 Scott Senick Varian Medical United States Eclipse IMRT 18 6FFF 4718 140.02
17 Delphine Rebullida Accuray France Ring Gantry Helical Arc 16 140.00
18 Gajendran N Regency Healthcare, Kanpur (India) India Eclipse VMAT 66 1399 139.81
19 Rolland Julien IPC ‐ CHICAS France RayStation VMAT 46 865 139.67
20 Eddie Chu St. Teresa's Hospital Hong Kong Eclipse VMAT 14 10 + 10FFF 2363 139.46
21 Madison Newkirk University of Arkansas for Medical Sciences United States Eclipse VMAT 4 10 972 139.16

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List of High Performers:
Top 20% Photon Plans: Eclipse TPS
Place Participant Name Institution Country Delivery # Beams Energy (MV) Total MU Score
1 Kwong Tsun Yin Keith St. Teresa's Hospital Hong Kong VMAT 14 10FFF 2756 146.01
2 Yik Shing Cheung St. Teresa's Hospital Hong Kong VMAT 12 10FFF 3013 145.81
3 Tso Gary Ka Ya St. Teresa's Hospital Hong Kong VMAT 18 10FFF 2142 145.77
4 Kai Leung Li St. Teresa's Hospital Hong Kong VMAT 14 10FFF 2339 145.13
5 Lee Chun Long St. Teresa's Hospital Hong Kong VMAT 15 10FFF 2025 145.07
6 xielunqi China AnShan city cancer hospital China IMRT 20 6 4275 143.80
7 zhanyingjie China  China IMRT 20 6 4334 143.08
8 Teresa Chim St. Teresa's Hospital Hong Kong VMAT 14 10 + 10FFF 2534 142.66
9 Liqinghao Anshan tumor hospital China IMRT 20 6 3858 142.26
10 R. Ngan sheffield hallam university Hong Kong VMAT 8 10FFF 2932 141.46
11 Dalibor Lojko Nemocnica AGEL Komarno s.r.o. Slovakia VMAT 6 6FFF 1584 140.48
12 Scott Senick Varian Medical United States IMRT 18 6FFF 4718 140.02
13 Gajendran N Regency Healthcare, Kanpur (India) India VMAT 66 1399 139.81
14 Eddie Chu St. Teresa's Hospital Hong Kong VMAT 14 10 + 10FFF 2363 139.46
15 Madison Newkirk University of Arkansas for Medical Sciences United States VMAT 4 10 972 139.16
16 wanglu Anshan Cancer Hospital China VMAT 7 6FFF 3119 139.08
17 Thomas Costantino CTSI/ Instructor JPU United States VMAT 4 10 1298 139.03
18 Patricia Hua UCSD Moores Cancer Center United States VMAT 46 1356 138.43
19 Cheuk Leung Chris O'Brien Lifehouse Australia VMAT 8 10 879 138.20
20 Tanja Weiss Klinikum Traunstein; Dep of Radiotherapy Germany VMAT 56 1209 138.18
21 Jonathan Stenbeck Prisma Health United States VMAT 46 1177 138.00
22 Gajendran N Regency Hospital Ltd India VMAT 66 1363 137.71
23 Thomas Hecker Kliniken Südostbayern AG Germany VMAT 46 1231 137.38
24 Simon Heinze Kantonsspital St.Gallen Switzerland VMAT 46 1133 137.19
25 Karthik Nagamuthu Purbanchal Cancer Hospital Nepal IMRT 96 1082 136.38

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List of High Performers:
Top 20% Photon Plans: Monaco TPS

Place Participant Name Institution Country Delivery # Beams Energy (MV) Total MU Score

1 Paul Barry Elekta United States VMAT 8 10 2550 142.89
2 Emily Basset Elekta United Kingdom VMAT 2 10 1851 138.60
3 Roberto Pellegrini Elekta Italy VMAT 2 10 1845 138.51
4 caocan Anshan Cancer Hospital China VMAT 7 6FFF 3298 135.84
5 David Ly Elekta Australia VMAT 2 10 1611 134.37
6 Randy Larson Elekta United States VMAT 26 937 133.73
7 James Clarke Elekta United States VMAT 3 10 1098 130.60
8 Vaclav Bednar Svet zdravia, a.s. Slovakia IMRT 76 709 127.74

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List of High Performers:
Top 20% Photon Plans: RayStation TPS

Place Participant Name Institution Country Delivery # Beams Energy (MV) Total MU Score

1 Mark Bowers Moffitt Cancer Center United States VMAT 8 6FFF 1641 141.66
2 Rolland Julien IPC ‐ CHICAS France VMAT 46 865 139.67
3 Amanuel Negussie Inova Schar Cancer Institute United States VMAT 46 1183 135.88
4 Alexa Diaz Moffitt Cancer Center United States VMAT 8 6FFF 1241 135.02
5 Vincent Jöst RaySearch Laboratories Germany VMAT 6 6FFF 1312 134.89
6 Max Richardson University of Cincinnati/Barrett Cancer Center United States VMAT 4 10 + 6 468 134.88

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List of High Performers:
Top 20% Photon Plans: Pinnacle TPS

Place Participant Name Institution Country Delivery # Beams Energy (MV) Total MU Score

1 Takuya Ito Tomei Atsugi Hospital Japan VMAT 2 10 + 6 976 135.09
2 Phil Bowen Agnesian Cancer Center/SSM Health United States VMAT 14 10 + 18 + 6 2160 132.72
3 BOSC CHU Brest France VMAT 26 726 130.33
4 Mis Alison France VMAT 26 637 129.64

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List of High Performers:
Top 20% Photon Plans: TomoTherapy TPS

Place Participant Name Institution Country Delivery # Beams Energy (MV) Total MU Score

1 John Dooley Accuray United States Helical Arc 16 141.15
2 Richard Braun Accuray Germany Helical Arc 16 141.13

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What have we learned…. 

• Thoracic cases can be challenging to deliver a 
definitive dose while maintaining healthy 
tissue constraints 
• Multiple ways to approach the same case
• Communication is key 
• Practice makes perfect

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Tips and Tricks Contributions

• Lesley Rosa • Philip Bowen
• Nicolas Depauw • Mark Bowers
• Stephen Zieminski • Amanuel Negussie
• Lou Bosc • James Henry
• David Littlejohn • Julien Rolland
• Kwong Tsun Yin  • Paul Barry
• Matthew Yik • Richard Braun
• Laertes Papaspyrou • Scott Senick
• Takuya Ito • Delphine Rebullida
• Raymond Dalfsen • Zamaltdinov Rail 
• Brain Neal • Lunqi Xie

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Special Thanks…

• Ranh Voong, MD ‐ Radiation Oncologist, JHU

• Kalin Shipman, CMD ‐ Efficiency Expert at Radformation

• Ashley Fellows CMD, RT(T) ‐ JHU

• Rick Scherer CMD, RT(T)(R) ‐ ProKnow Clinical Application Specialist at Elekta

• Ben Nelmes, PhD – President and Founder of ProKnow

• Kyle Burnett ‐ProKnow Engineer

• Elekta for sponsorship

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Thank You!!

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