3D-CRT, IMRT and VMAT for flank irradiation due to pediatric Wilms tumor: A comparative planning study with XCAT phantoms

Purpose: To compare the dosimetric parameters and radiogenic risks from 3D-CRT, IMRT and VMAT for flank irradiation due to pediatric Wilms tumor. Methods: Two computational XCAT phantoms simulating an average 5- and 10-year-old patient were used. Four different planning target volumes (PTVs) for right flank (RF) and left flank (LF) irradiation with or without paraaortic lymph nodes (LNs) and eight surrounding organs-at-risk (OARs) were contoured on the phantoms' CT sections. Forty-eight 3D-CRT, IMRT and VMAT plans were created using 6 and 10-MV photons on the two phantoms. The target coverage index (TCI), homogeneity index (HI), conformity index (CI), conformation number (CN) and OAR exposure were determined through dose-volume histogram (DVH) analysis. Second cancer risks were estimated using a non-linear model and DVH data. Results: The IMRT and VMAT for LF + LN and RF + LN irradiation reduced the radiation dose to four to six out of the eight OARs compared to 3D-CRT. Conventional treatment provided a better organ sparing for RF and LF irradiation. The IMRT and VMAT led to superior planning parameters in respect to 3D-CRT for all PTVs and both patient's ages (3D-CRT: TCI = 59.80 % - 82.26 %, CI = 0.55-0.81, CN = 0.40-0.64, HI = 1.11-1.15; IMRT: TCI = 96.04 % - 99.72 %, CI = 0.85-0.91, CN = 0.85-0.88, HI = 1.03-1.05; VMAT: TCI = 96.02 % - 99.69 %, CI = 0.86-0.91, CN = 0.85-0.89, HI = 1.03-1.06). The excess-absolute-risk for developing secondary small intestine, liver and stomach malignancies from 3D-CRT were (7.99-19.32) x 10-4, (0.29-3.83) x 10-4 and (0.37-4.50) x 10-4 persons-year, respectively. The corresponding risks from intensity modulated techniques reached to 22.26 x 10-4, 4.58 x 10-4 and 5.42 x 10-4 persons-year. Conclusions: This dataset related to plan quality, radiation dose and risks to OARs allows the selection of the proper treatment technique for flank irradiation based on the patient's age and target site.

Automated summary

This study compares the dosimetric parameters and radiogenic risks of three different irradiation techniques (3D-CRT, IMRT, and VMAT) for pediatric Wilms tumor flank irradiation. IMRT and VMAT showed better organ sparing and superior planning parameters compared to 3D-CRT. The risks of developing secondary malignancies were also higher with the intensity modulated techniques.