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Noninvasive Cardiac Ablation to Treat Ventricular Tachycardia - Optimized Volumetric Modulated Arc Therapy Technique for Varian Edg and Halcyon Delivery Systems

S Goddu1*, (1) Washington University, St. Louis, MO


(Monday, 7/15/2019) 3:45 PM - 4:15 PM

Room: Exhibit Hall | Forum 4

Purpose: Recent publications (Cuculich et al., NEJM,2017 & Robinson et al., Circulation,2019) have  shown  promising outcomes of non-invasive cardiac radio-ablation  using  single-fraction-SBRT to treat patients with refractory, life-threatening, Ventricular Tachycardia (VT). In this treatment-planning study we attempted to optimize and standardize the Volumetric Modulated Arc Therapy (VMAT) planning technique to achieve better dose conformity and greater Non-Target Heart-Tissue (NTHT) sparing.

Methods: Thirteen patients were selected who previously received single-fraction-SBRT as part of a phase_I/II_clinical trial (NCT02919618). Doses of 35Gy to ITV and 25Gy to PTV were delivered by 3 non-coplanar VMAT arcs of 6MV_FFF on a Varian Edge linear accelerator. Patients were retrospectively re-planned using 10 optimized VMAT arcs (10arcs_plans) with unique collimator angles using 6MV_FFF on Halcyon (Halc_6x), and 6MV_FFF (Edge_6x) and 10MV_FFF (Edge_10x) on Edge. Optimization goals were to improve dose conformity while maximizing the NTHT sparing and meeting the protocol constraints of stomach, esophagus and colon (OARs). 10arcs_plans were compared against the clinical plans.

Results: Optimized 10arcs_plans improved the dose conformity (Clin:1.14±0.12 vs. Halc_6x:1.08±0.05, Edge_6x:1.02±0.04, Edge_10x:1.03±0.03) and reduced gradient measure (Clin:2.01±0.47 vs. Halc_6x:1.79±0.28cm, Edge_6x:1.76±0.47cm, Edge_10x:1.55±0.26cm) while achieving adequate V95%Rx coverage for the ITV (clin:99.7±0.4% vs Halc_6x:99.6±0.4%, Edge_6x:99.3±0.8%, Edge_10x:98.7±2.0%) and the PTV (Clin:99.7±0.4% vs. Halc_6x:97.2±1.8%, Edge_6x:96.8±2.2%, Edge_10x:97.1±1.8%). 10arcs_plans reduced the NTHT-mean-dose (Clin:6.2±2.1Gy vs. Halc_6x:3.9±1.0Gy, Edge_6x:3.7±1.1Gy, Edge_10x:4.0±1.1Gy) and the V20Gy (Halc_6x:35cc, Edge_6x:43cc, Edge_10x:38cc), V10Gy (Helc_6x:137cc, Edge_6x:159cc, Edge_10x:141cc) and V5Gy (Helc_6x: 219.0cc, Edge_6x:247cc, Edge_10x:206cc). All VMAT plans met the protocol objectives for the other OARs. For the 10arcs_plans the MU-ratio was increased from 2.66±0.26 to 3.74±0.32 for Halc_6x and 3.49±0.38 for the Edge_6x and 2.92±0.30 for the Edge_10x.

Conclusion: All 10arcs_plans provided better dose conformity and gradient while allowing greater sparing of NTHT from doses associated with increased risk for complications. Coplanar plans on a ring gantry system such as Halcyon appear clinically similar to Edge plans.


Heart, Stereotactic Radiosurgery, Rotational Therapy


TH- External beam- photons: VMAT dose optimization algorithms

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