Tangential Volumetric Modulated Radiotherapy - A New Technique for Large Scalp Lesions with a Case Study in Lentigo Maligna

• Main Authors: E. Daniel Santos, Julia A. Green, Nastik Bhandari, Angela Hong, Pascale Guitera, Gerald B. Fogarty
• Format: Article
• Language: English
• Published: Bulgarian Academy of Sciences 2015-06-01
• Series: International Journal Bioautomation
• Subjects: Lentigo; Maligna; Volumetric; Modulated; Radiotherapy; Brachytherapy
• Online Access: http://www.biomed.bas.bg/bioautomation/2015/vol_19.2/files/19.2_08.pdf
• ISSN: 1314-1902; 1314-2321

Introduction: Dose homogeneity within and dose conformity to the target volume can be a challenge to achieve when treating large area scalp lesions. Traditionally High Dose Rate (HDR) brachytherapy (BT) scalp moulds have been considered the ultimate conformal therapy. We have developed a new technique, Tangential Volumetric Modulated Arc Therapy (TVMAT) that treats with the beam tangential to the surface of the scalp. In the TVMAT plan the collimating jaws protect dose-sensitive tissue in close proximity to the planning target volume (PTV). Not all the PTV is within the beam aperture as defined by the jaws during all the beam-on time. We report the successful treatment of one patient. Methods: A patient with biopsy proven extensive lentigo maligna on the scalp was simulated and three plans were created; one using a HDR brachytherapy surface mould, another using a conventional VMAT technique and a third using our new TVMAT technique. The patient was prescribed 55 Gy in 25 fractions. Plans were optimised so that PTV V100% = 100%. Plans were compared using Dose-Value Histogram (DVH) analysis, and homogeneity and conformity indices. Results: BT, VMAT and TVMAT PTV median coverage was 105.51%, 103.46% and 103.62%, with homogeneity index of 0.33, 0.07 and 0.07 and the conformity index of 0.30, 0.69 and 0.83 respectively. The median dose to the left hippocampus was 11.8 Gy, 9.0 Gy and 0.6 Gy and the median dose to the right hippocampus was 12.6 Gy, 9.4 Gy and 0.7 Gy for the BT, VMAT and TVMAT respectively. Overall TVMAT delivered the least doses to the surrounding organs, BT delivered the highest. Conclusions: TVMAT was superior to VMAT which was in turn superior to BT in PTV coverage, conformity and homogeneity and delivery of dose to the surrounding organs at risk. The patient was successfully treated to full dose with TVMAT. TVMAT was verified as being the best amongst the three techniques in a second patient.