Non-Coplanar treatments

Recent studies show non-coplanar treatments can deliver clinically relevant improvements to treatment plans¹, specifically in lung cancer ^2,^3,^4,⁵ breast cancer ^6,^7,^8,^9,, head and neck cancer ^10,^11,^12,^13,¹⁴, lymphoma^15, ^16, and high-grade glioma ¹⁷. Traditionally, non-coplanar treatments require extra planning and machine time, both for dry runs and treatments. Additionally, some non-coplanar plans are not deliverable, which can lead to complicated re-planning and repeat quality assurance work, leading to delays in patient treatment and increased costs. 

MapRT is designed to help overcome the practical challenges of non-coplanar treatments: checking for usable beam and couch angles during planning, mapping safe beam transitions and showing the maximum safe couch and gantry angles that are possible for each patient in their treatment position.

You can find out more about MapRT here.

Recent Research on Non-Coplanar Treatments:

The additional degrees of freedom are shown to increase the therapeutic ratio, either through dose escalation to the target or dose reduction to functionally important organs at risk, by multiple research groups. Although significant work is still needed to translate these new non-coplanar radiotherapy techniques into the clinic, clinical implementation should be prioritized.¹

Nine [lung cancer] studies were included and evaluated in the meta-analysis and treatment plans were designed with both coplanar beam arrangements CBA and non-coplanar beam arrangements (NCBA). After combining multicenter results, NCBA plans have significant advantages in reducing V20 of the whole lung and max dose of spinal cord [versus CBA].²

Non-coplanar VMAT proposed in this study showed more favorable plan quality than the coplanar VMAT plans for lung SABR with tumors located close to the heart.³

Static couch non-coplanar optimization yielded maximum dose reductions to OARs while maintaining target conformity for lung SBRT.⁴

For middle and lower lung tumors…a significant reduction in equivalent uniform dose, V30, V40 and V50 is observed for the heart when either non-coplanar fields or IMRT is used. IMRT also reduces the lung NTCP, V5, V13, V20 and V30 values and esophagus NTCP.⁵

Doses to the heart and ipsilateral lung were significantly lower with non-coplanar VMAT compared to both coplanar VMAT and 3D-CRT. Non-coplanar VMAT reduced doses to both the contralateral breast and lung compared to coplanar VMAT and achieved levels similar to 3D-CRT for the contralateral breast and moderately higher doses for the contralateral lung. Delivery of high doses (>30 Gy) to the contralateral side was completely avoided with non-coplanar VMAT, contrary to the results for coplanar VMAT and 3D-CRT.⁶

[In left-sided breast cancer] Compared to coplanar VMAT, non-coplanar VMAT provides improved conformity and homogeneity of whole PTV, better dose sparing of the heart, bilateral lungs, left anterior descending coronary artery (LAD), and right breast for locoregional radiotherapy of left-sided breast cancer with IMN, potentially reducing the risk of normal tissue damage.⁷

[In this study of bilateral breast cancer cases] VMAT plans with non-coplanar beam arrangements had significant dosimetric advantages in terms of sparing of critical organs, that is D_mean of heart doses with almost equivalent lung doses and equally good target coverage.⁸

[For patients in our study of] postoperative stereotactic body radiotherapy (SBRT) in case of high-risk margins for pT1-T2/N0 oropharyngeal and oral cavity tumors … VMAT coplanar + non-coplanar had better dosimetric outcomes than VMAT coplanar and has become the standard technique for patients treated … in our institution. Acute toxicity appears acceptable.⁹

For the first 15 patients on a prospective phase II clinical trial exploring the safety, feasibility, and efficacy of the [non-coplanar] technique for recurrent head and neck cancer treatment. … statistically significant increases in dose conformity and mean PTV and GTV doses. With a median follow-up of 12 months … patient-reported QOL metrics were favorable. … treatment delivery was feasible, safe, and well-tolerated by patients. ¹⁰

Twenty-five previously treated patients of HNC underwent re-planning to improve the dose distributions with either coplanar VMAT technique … or noncoplanar … VMAT plans. [Non-coplanar] VMAT plans allowed to decrease the dose-volume-metrics for relevant OAR and results are reliable from a dosimetric standpoint.¹¹

[In treatment of nasopharyngeal tumours] VMAT using optimized non-coplanar irradiation trajectories reduced the mean and maximum doses in organs at risk compared to coplanar VMAT plans by 19% on average while the target coverage remains constant.¹²

VMAT provided significantly better target coverage, in terms of V100% (Volume encompassed by the isodose 100%), than IMRT, in particular when nc-VMAT was used. In general, organ at risk sparing is similar with the three approaches, although nc-VMAT can allow a statistically significant reduction of dose to contralateral parotid gland and cochlea.¹³

Overall there was a clear tendency towards higher plan quality with non-coplanar configurations. B-VMAT resulted in reduced low-dose spread in lungs and left breast. Non-coplanar beam configurations were favorable for young female mediastinal lymphoma patients, with patient-specific and plan-parameter-dependent dosimetric advantages.¹⁴

Non-coplanar IMRT had better PTV coverage and OARs sparing, except for being larger in V5 to breast and lung. In IMRT for young female patients with mediastinal lymphoma, using of non-coplanar IMRT significantly reduces the radiation dose to the breasts and lungs compared with coplanar IMRT, and consequently reduces the risk of breast second cancer and pulmonary toxicity. Besides young female patients, non-coplanar IMRT can also benefit other mediastinal lymphoma patients. ¹⁵

Mean and maximum organ at risk doses were equal or significantly lower (P < .05) with 4π than with VMAT. Particularly substantial dose reduction of 2.92 Gy in the average accumulated brainstem maximum dose enabled treatments that would otherwise not satisfy safe dose constraints with VMAT. Treatments were well tolerated, with an average patient comfort score of 8.6/10. Intrafractional motion was <1.5 mm for all delivered fractions, and the average delivery time was 34.1 minutes.¹⁶

Find out more about MapRT and SGRT for clearance mapping

1. Smyth G, Evans PM, Bamber JC, Bedford JL. Recent developments in non-coplanar radiotherapy. Br J Radiol. 2019 May;92(1097):20180908. doi: 10.1259/bjr.20180908. Epub 2019 Feb 1. PMID: 30694086; PMCID: PMC6580906.

2. Ma M, Ren W, Li M, Niu C, Dai J. Dosimetric comparison of coplanar and non-coplanar beam arrangements for radiotherapy of patients with lung cancer: A meta-analysis. J Appl Clin Med Phys. 2021 Apr;22(4):34-43. doi: 10.1002/acm2.13197. Epub 2021 Feb 26. PMID: 33634946; PMCID: PMC8035566.

3. Kim ST, An HJ, Kim JI, Yoo JR, Kim HJ, Park JM. Non-coplanar VMAT plans for lung SABR to reduce dose to the heart: a planning study. Br J Radiol. 2020 Jan;93(1105):20190596. doi: 10.1259/bjr.20190596. Epub 2019 Oct 22. PMID: 31625759; PMCID: PMC6948076..

4. Lincoln JD, MacDonald RL, Syme A, Thomas CG. Static couch non-coplanar arc selection optimization for lung SBRT treatment planning. Phys Med Biol. 2023 Jul 21;68(15). doi: 10.1088/1361-6560/ace23f. PMID: 37369237.

5. Chapet O, Khodri M, Jalade P, N’guyen D, Flandin I, D’hombres A, Romestaing P, Mornex F. Potential benefits of using non-coplanar field and intensity modulated radiation therapy to preserve the heart in irradiation of lung tumors in the middle and lower lobes. Radiother Oncol. 2006 Sep;80(3):333-40. doi: 10.1016/j.radonc.2006.07.009. Epub 2006 Aug 24. PMID: 16934354.

6. J, F., et al. (2023). Locoregional breast radiotherapy including IMN: optimizing the dose distribution using an automated non-coplanar VMAT-technique. Acta oncologica (Stockholm, Sweden), [online] 62(10). doi:https://doi.org/10.1080/0284186X.2023.2264488.

7. Xu, Y., Ma, P., Hu, Z., Tian, Y., Men, K., Wang, S., Xu, Y. and Dai, J. (2021). Non-coplanar volumetric modulated arc therapy for locoregional radiotherapy of left-sided breast cancer including internal mammary nodes. Radiology and Oncology, 55(4), pp.499–507. doi:https://doi.org/10.2478/raon-2021-0045.

8. A, B., et al. (2023). Dosimetric Comparision of Coplanar versus Non-coplanar Volumetric Modulated Arc Therapy for Treatment of Bilateral Breast Cancers. Journal of medical physics, [online] 48(3). doi:https://doi.org/10.4103/jmp.jmp_36_23.

9. Biau J, Lopez L, Thivat E, Casile M, Millardet C, Saroul N, Pham-Dang N, Molnar I, Bourhis J, Lapeyre M. Postoperative SBRT in the treatment of early-stage oropharyngeal and oral cavity cancers with high-risk margins: A dosimetric comparison of volumetric modulated arc therapy with or without non-coplanar arcs and acute toxicity outcomes from the STEREOPOSTOP GORTEC 2017-03 phase 2 trial. Clin Transl Radiat Oncol. 2022 Nov 14;38:169-174. doi: 10.1016/j.ctro.2022.11.007. PMID: 36466746; PMCID: PMC9712819.

10. Woods KE, Ma TM, Cook KA, Morris ED, Gao Y, Sheng K, Kishan AU, Hegde JV, Felix C, Basehart V, Narahara K, Shen Z, Tenn S, Steinberg ML, Chin RK, Cao M. A Prospective Phase II Study of Automated Non-Coplanar VMAT for Recurrent Head and Neck Cancer: Initial Report of Feasibility, Safety, and Patient-Reported Outcomes. Cancers (Basel). 2022 Feb 14;14(4):939. doi: 10.3390/cancers14040939. PMID: 35205686; PMCID: PMC8870161.

11. Gayen S, Kombathula SH, Manna S, Varshney S, Pareek P. Dosimetric comparison of coplanar and non-coplanar volumetric-modulated arc therapy in head and neck cancer treated with radiotherapy. Radiat Oncol J. 2020 Jun;38(2):138-147. doi: 10.3857/roj.2020.00143. Epub 2020 May 26. PMID: 33012157; PMCID: PMC7533406.