Total Scalp Irradiation: The Comparison of Five Different Plans Using Volumetric Modulated Arc Therapy- Simultaneous Integrated Boost (VMAT-SIB) Technique
1Department of Radiation Oncology, Recep Tayyip Erdoğan University Faculty of Medicine, Rize-Turkey DOI : 10.5505/tjo.2017.1609


The aim of this study was to show that the optimum dosage can be delivered to the target organs at risk (OAR) by radiotherapy, which becomes more complicated because of technical difficulties arising from irregular, convex, and complex geometrical structure of the target, such as scalp irradiation, and because of situations resulting from the necessity of bolus of the lesion and immobilization as well as the proximity to neighboring critical organs using the VMAT-SIB technique.

Five different VMAT-SIB schemes were designed using the Varian Trilogy IX linear accelerator (Varian Medical Systems) for total scalp irradiation and bilateral neck irradiation. These different VMAT scehemes were compared with respect to a dose volume histogram of obtained data, homogeneity, indices, conformity index, OAR, and doses of target volumes.

The patient-designed bolus plan 1 with two isocenters was chosen as the most appropriate plan. Plans 2, 3, 4, and 5 were inappropriate plans because the application of the virtual bolus in plan 2 was difficult, plan 3 with one isocenter was unacceptable with respect to the value of conformity index, plan 4 with three isocenters had a matching field, and plan 5 in which different priority values were used had an increase in OAR doses.

VMAT-SIB can be preferred as an appropriate radiotherapy technique as it can provide optimum and allowable OAR doses in tumors requiring an intensive treatment planning effort.


Angiosarcoma is a rare aggressive malignant tumor originating from the vascular and lymphatic endothelium.[1] It accounts for 15% of head and neck sarcomas and approximately 1%?2% of sarcomas.[2,3] The disease is usually found on the scalp and face and is frequently fatal.[4,5] Cutaneous angiosarcomas are the most common subtype of angiosarcomas, with male predominance, usually observed in the 65?70 age range.[6,7] Scalp angiosarcoma is an aggressive form of angiosarcoma with a very high metastatic spread and local recurrence tendency.[6] According to the Surveillance, Epidemiology and End Results (SEER) 1973?2007 data, the overall 5- and 10-year survival rates were 34% and 14%, respectively.[7] Although there is no optimal treatment, therapies including surgery, radiotherapy (RT), taxane-based chemotherapy (ChT), and targeted therapies are used. Despite these treatments, the prognosis is still poor. Because of high local recurrence rates, postoperative RT is usually performed postoperatively. Historically, irradiation methods for this disease have progressed in parallel to the RT device and technical development. Based on the literature view, it appears that detailed data were not provided in relation to RapidArc rotational VMAT, a relatively new technique. In this study, TSI was performed using the RapidArc VMAT method and a large area RT involving the bilateral neck was performed using the VMAT-SIB technique, whereas the organs at risk (OAR) were also appropriately protected. Data obtained from the dose volume histogram (DVH), homogeneity index (HI), conformity index (CI), OAR, and doses the target volumes required were compared using five different VMAT plans.


It is known that angiosarcomas in the scalp tend to be seen in elderly patients.[1] The patients are aged in the range of 65-70 years and there is a male dominance. [4,5] Although our patient was male, comparable with the literature, he was 54 years old, and hence relatively younger than those reported in the literature.

The etiology of angiosarcoma includes exposure to radiation. Radiation-induced angiosarcoma typically develops 5-10 years after irradiation, whereas longer latency periods have also been shown after head and leg irradiation.[17] Other risk factors for angiosarcoma are exposure to vinyl chloride and thorium dioxide (thorotrast). It was suggested that exposure to ultraviolet light also contributes to angiosarcomas because they occur in areas exposed to sunlight, such as the skin of the head. It is known that basal and squamous skin cancers arise after exposure to sunlight. Considering the frequency of these two cancers, the likelihood of coexistence with angiosarcoma may be high. However, in a study, it was found that only 3 of the 18 patients with angiosarcoma had a history of basal or squamous skin cancer.[18] This situation suggests that sunlight exposure is not an important agent. Scalp angiosarcoma was suggested to be caused by trauma, but trauma is seen as a more likely reason for the lesion being recognized by the patient.[17,18] Our patient also noticed his lesion after a trauma, and there was a history of sunlight exposure at an altitude of approximately 2000 m since childhood. To the best of our knowledge, this has never been reported in the literature. In general, ultraviolet radiation is divided into three types as UV-A, UV-B, and UV-C; UV-C is held responsible to a greater extent in skin cancer etiology; and we think that the condition in our patient, who has been exposed to UV-C since childhood (which is denser at high altitudes), may be a risk factor for angiosarcoma.

Because scalp angiosarcoma is so rare, there is no standardized treatment for the disease and treatment decisions have often been made on retrospective heterogeneous patient profiles and on judgments in other soft tissue sarcoma treatment algorithms.[19] The general treatment modality in angiosarcoma includes wide resection, RT, and ChT options. Combined therapy modalities are recommended to improve prognosis. [20] The recommended treatment for local disease is radical surgery including complete resection and adjuvant RT.[21,22] However, despite large resections, clean surgical margins are rarely obtained.[21] Concomitant RT with taxane-based ChT is thought to be a very reasonable method for large cutaneous angiosarcoma cases, whereas it is a method that is particularly difficult to manage in comparison to surgical RT combinations. [23] Although the locoregional response rate was reported to be 94% with taxane-based ChT and concomitant RT, the 5-year overall survival rate in these patients was statistically higher than that with conventional surgery and RT (56% and 8%, respectively, p<0.01).[23] In the study by Miki et al.[24], patients treated with chemoradiotherapy using docetaxel showed better overall survival and distant metastasis rates than those treated with chemoradiotherapy without docetaxel. As seen, concomitant RT with taxane-based ChT is an effective approach for treating angiosarcoma. Therefore, taxanes are preferred because of their higher effectiveness in simultaneous treatments.[7] Docetaxel is a well-known antimitotic drug, and the effect mechanism of paclitaxel from the same group of chemotherapeutic drugs is similar to that of docetaxel. However, it is known that docetaxel is more cytotoxic, probably because of its faster intracellular uptake.[25,26] In addition, paclitaxel has antiangiogenic and apoptotic effects. Because the source of angiosarcoma is the endothelial cells, it is believed that the anti-angiogenic activity of the drug is responsible for the positive effect of paclitaxel treatment.[27] In patients with distant metastases, there are data demonstrating the benefit of vascular endothelial growth factor receptors inhibitor bevacizumab in combination with paclitaxel ChT in improving the quality of life and survival.[28] For metastatic angiosarcoma, ChT is the primary treatment option.[29] However, there is no standard ChT regime. Liposomal doxorubicin, paclitaxel, and docetaxel were reported to be beneficial in retrospective studies.[30-34] Local recurrence rates recorded in different series ranged from 53% to 100%, whereas distant metastasis rates ranged from 28% to 64%.[35-37]

Because of high recurrence rates, adjuvant RT is provided postoperatively. During TSI, regional lymphatics are also required to be coirradiated.[29] In our patient, TSI and bilateral neck irradiation were performed because neck lymphatics were involved.

In the 80s and 90s, TSI was attempted with electron therapy techniques, and techniques, such as overlapping, shifting, and overlaying, were used in electron fields to create enough dosage to cover the target volumes of the dermis and epidermis.[38-40] This caused difficulties in RT administration as well as problems associated with dose inhomogeneity and electron scattering.[41] In the 2000s, these obstacles were partially solved with advanced technology modern RT techniques in combination with IMRT or photon-electron combination therapy techniques; problems in field composition were minimized while the target dose wrapping and dose homogeneity were improved.[41-44] As of 2009, it was observed that the TSI approach range extends from photon-electron based combined techniques to include IMRT, VMAT, tomotherapy, and high-dose rate brachytherapy.[45-47] When VMAT plans with the RapidArc software were implemented in 2017, it was considered as a new choice for TSI. Hu et al.[10] reported that IMRT was less effective in protecting optic structures than 3D conformal RT (3D-CRT), whereas RapidArc provided treatment without increasing optic system doses. IMRT significantly reduced brain doses in comparison to 3D-CRT, providing better results in terms of target and brain protection.[48] Song et al.[49] found that VMAT and tomotherapy were superior to the photon-electron approach in brain protection. Although brain and brainstem protection is best achieved by VMAT, tomotherapy provided the possibility of irradiation without the problem of intersection receiving large treatment areas.[50] Difficulties are experienced in planning 3 PTV optimization and planning from one isocenter in large area treatments performed using Eclipse treatment planning systems. The use of multiple isocenters is a problem that the physician faces in the planning phase and a situation that requires careful attention during the setup phase. Here, besides the intersection of the fields, because there are different isocenters, each isocenter shows up as a different setup and this also increases the intensity of the work.


Scalp angiosarcoma is a rare, aggressive tumor that mainly affects elderly individuals. Despite radical surgical treatments, it still has a very high local recurrence rate. Optimal device and the most effective RT technique should be used in accordance with the condition of the clinic and technological developments because postoperative RT including TSI and neck lymphatics covers a wide and complex area.

Peer-review: Externally peer-reviewed.
Conflict of Interest: None declared.
Authorship contributions: Concept - S.Y.R; Design - S.Y.R; Supervision - S.Y.R; Materials - S.Y.R; Data collection &/or processing - S.Y.R, Y.Ç, M.E; Analysis and/or interpretation - S.Y.R; Literature search - S.Y.R; Writing - S.Y.R; Critical review - S.Y.R


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