Medical Oncology

, 35:150 | Cite as

Volumetric modulated arc therapy (VMAT) in the treatment of esophageal cancer patients

  • Stefania Martini
  • Francesca Arcadipane
  • Paolo Strignano
  • Rosella Spadi
  • Viviana Contu
  • Christian Fiandra
  • Riccardo Ragona
  • Giorgia Catalano
  • Maria Antonietta Satolli
  • Michele Camandona
  • Renato Romagnoli
  • Umberto Ricardi
  • Pierfrancesco FrancoEmail author
Original Paper


The aim of the study is to evaluate feasibility, safety, toxicity profile, and dosimetric results of volumetric modulated arc therapy (VMAT) to deliver definitive or pre-operative radiation in locally advanced esophageal cancer patients. A total of 68 patients were treated with VMAT between March 2014 and March 2018 (44% vs 56% for definitive and neoadjuvant settings, respectively). Dose prescription differed depending on the clinical scenario (54–60 Gy in 30 fractions for definitive treatments; 41.4/45 Gy in 23–25 fractions in the pre-operative setting). Most of the patients were given concurrent chemotherapy. Two coplanar and one non-coplanar arcs were employed for VMAT delivery. Treatment was generally well tolerated. Acute toxicity was generally mild. In patients treated with definitive intent, ≥ G3 toxicities were observed for esophagitis (30%), anorexia (26.7%), fatigue (26.7%), nausea (6.7%), and vomiting (3.3%). In patients treated within a neoadjuvant approach, ≥ G3 anorexia (21%), esophagitis (15.8%), fatigue (13.3%), nausea (5.3%), and vomiting (2.6%) were observed. Dosimetric results were consistent in term of both target coverage and normal tissue sparing. In conclusion, VMAT proved to be a feasible, safe, and effective strategy to deliver definitive or pre-operative radiation in locally advanced esophageal cancer patients.


Esophageal cancer Gastro-esophageal junction VMAT IMRT Radiotherapy Chemoradiation Pre-operative treatments 



None to declare.

Compliance with ethical standards

Conflict of interest

We declare that we do not have any conflict of interest.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The present study has been reviewed and approved by the Internal Review Board of the Department of Oncology of the University of Turin at AOU Citta’ della Salute e della Scienza, Turin, Italy.


  1. 1.
    Martin-Richard M, Diaz Beveridge R, Arrazubi V, Alsina M, Galan Guzman M, Custodio AB, et al. SEOM clinical guideline for the diagnosis and treatment of esophageal cancer. Clin Transl Oncol. 2016;18:1179–86.CrossRefGoogle Scholar
  2. 2.
    Lordick F, Mariette C, Haustermans K, Obermannova R, Arnold D, on behalf of the ESMO Guidelines Committee. Oesophageal cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow up. Ann Oncol. 2016;27:v50–7.CrossRefGoogle Scholar
  3. 3.
    Castro C, Bosetti C, Malvezzi M, et al. Patterns and trends in esophageal cancer mortality and incidence in Europe (1980–2011) and predictions to 2015. Ann Oncol. 2014;25:283–90.CrossRefGoogle Scholar
  4. 4.
    Kuwano H, Nishimura Y, Oyama T, Kato H, Kitagawa Y, Kusano M, et al. Guidelines for diagnosis and treatment of carcinoma of the esophagus April 2012 edited by the Japan Esophageal Society. Esophagus. 2015;12:1–30.CrossRefGoogle Scholar
  5. 5.
    Sohda M, Kurwano H. Current status and future prospects for esophageal cancer treatment. Ann Thorac Cardiovasc Surg. 2017;23:1–11.CrossRefGoogle Scholar
  6. 6.
    Franco P, Fiorentino A, Dionisi F, et al. Combined modality therapy for thoracic and head and neck cancer: a review of updated literature based on a consensus meeting. Tumori. 2016;102:459–71.CrossRefGoogle Scholar
  7. 7.
    Amini A, Ajani J, Komaki R, Allen PK, Minsky BD. Blum M, et al. Factors associated with local-regional failure after definitive chemoradiation for locally advanced esophageal cancer. Ann Surg Oncol. 2014;21:306–14.CrossRefGoogle Scholar
  8. 8.
    Munch S, Alchmeier S, Hapfelmeir A, Duma MN, Oechsner M, Felth M, et al. Comparison of dosimetric parameters and toxicity in esophageal cancer patients undergoing 3D conformal radiotherapy or VMAT. Strahlenther Onkol. 2016;192:722–9.CrossRefGoogle Scholar
  9. 9.
    Teoh M, Clark CH, Wood K, Whitaker S, Nisbet A. Volumetric modulated arc therapy: a review of current literature and clinical use in practice. Br J Radiol. 2011;84:967–96.CrossRefGoogle Scholar
  10. 10.
    Franco P, Arcadipane F, Ragona R, Mistrangelo M, Cassoni P, Munoz F, et al. Volumetric modulated arc therapy (VMAT) in the combined modality treatment of anal cancer patients. Br J Radiol. 2016;89(1060):20150832.CrossRefGoogle Scholar
  11. 11.
    Iorio GC, Franco P, Gallio E, Martini S, Arcadipane F, Bartoncini S, et al. Volumetric modulated arc therapy (VMAT) to deliver nodal irradiation in breast cancer patients. Med Oncol. 2018;35:1.CrossRefGoogle Scholar
  12. 12.
    Yin L, Wu H, Gong J, Geng JH, Jiang F, Shi AH, et al. Volumetric-modulated arc therapy vs c-IMRT in esophageal cancer: a treatment planning comparison. World J Gastroenterol. 2012;18:5266–75.CrossRefGoogle Scholar
  13. 13.
    Gong G, Wang R, Guo Y, Zhai D, Liu T, Lu J, et al. Reduced lung dose during radiotherapy for thoracic esophageal carcinoma: VMAT combined with active breathing control for moderate DIBH. Radiat Oncol. 2013;8:291.CrossRefGoogle Scholar
  14. 14.
    Nicolini G, Ghosh-Laskar S, Shristava SK, Banerjee S, Chaudhary S, Agarwal JP, et al. Volumetric modulation arc radiotherapy with flattening filter-free beams compared with static gantry IMRT and 3D conformal radiotherapy for advanced esophageal cancer: feasibility study. Int J Radiat Oncol Biol Phys. 2012;84:553–60.CrossRefGoogle Scholar
  15. 15.
    Radiation Therapy Oncology Group. Acute radiation morbidity scoring criteria. Accessed August 22 2018.
  16. 16.
    National Cancer Institute Cancer Therapy Evaluation Program. Common Toxiity Criteria for Adverse Events. Version 4.02. Accessed August 22 2018.
  17. 17.
    Franco P, Arcadipane F, Strignano P, et al. Pre-operative treatments for adenocarcinoma of the lower oesophagus and gastro-oesophageal junction: a review of the current evidence from randomized trials. Med Oncol. 2017;34:40.CrossRefGoogle Scholar
  18. 18.
    Hulshof MC, van Laarhoven HW. Chemoradiotherapy in tumours of the oesophagus and gastro-oesophageal junction. Best Pract Res Clin Gastroenterol. 2016;30:551–63.CrossRefGoogle Scholar
  19. 19.
    Burmeister BH, Smithers BM, Gebski V, Fitzgerald L, Simens RJ, Devitt P, et al. Surgery alone versus chemoradiotherapy followed by surgery for resectable cancer of the oesophagus: a randomised controlled phase III trial. Lancet Oncol. 2005;6:659–68.CrossRefGoogle Scholar
  20. 20.
    Garg PK, Sharma J, Jakhetiya A, Goel A, Gaur MK. Preoperative therapy in locally advanced esophageal cancer. World J Gastroenterol. 2016;22:8750–9.CrossRefGoogle Scholar
  21. 21.
    Van Benthuysen L, Hales L, Podgorsak MB. Volumetric modulated arc therapy vs IMRT for the treatment of distal esophageal cancer. Med Dosim. 2011;36:404–9.CrossRefGoogle Scholar
  22. 22.
    Fenkell L, Kaminsky I, Breen S, Huang S, Van Prooijen M, Ringash J. Dosimetric comparison of IMRT vs 3D conformal radiotherapy in the treatment of cancer of the cervical esophagus. Radiother Oncol. 2008;89:287–91.CrossRefGoogle Scholar
  23. 23.
    Fakhrian K, Oechsner M, Kampfer S, Schuster T, Molls M, Geinitz H. Advanced techniques in neoadjuvant radiotherapy allow dose escalation without increased dose to organs ar risk: planning study in esophageal carcinoma. Strahlenther Onkol. 2013;189:293–300.CrossRefGoogle Scholar
  24. 24.
    Roeder F, Nicolay NH, Nguyen T, Saleh-Ebrahimi L, Askoxylakis V, Bostel T, et al. Intensity modulated radiotherapy (IMRT) with concurrent chemotherapy as definitive treatment of locally advanced esophageal cancer. Radiat Oncol. 2014;9:191.CrossRefGoogle Scholar
  25. 25.
    Franco P, Arcadipane F, Ragona R, Mistrangelo M, Cassoni P, Racca P, et al. Hematologic toxicity in anal cancer patients during combined chemo-radiation: a radiation oncologist perspective. Expert Rev Anticancer Ther. 2017;17:335–45.CrossRefGoogle Scholar
  26. 26.
    Franco P, Arcadipane F, Ragona R, Lesca A, Gallio E, Mistragelo M, et al. Dose to specific subregions of pelvic bone marrow defined with FDG-PET as a predictor of hematologic nadirs during concomitant chemoradiation in anal cancer patients. Med Oncol. 2016;33:72.CrossRefGoogle Scholar
  27. 27.
    Wei X, Liu HH, Tucker SL, Wang S, Mohan R, Cox JD, et al. Risk factors for pericardial effusion in inoperable esophageal cancer patients treated with definitive chemoradiation therapy. Int J Radiat Oncol Biol Phys. 2008;70:707–14.CrossRefGoogle Scholar
  28. 28.
    Hawkins MA, Bedford JL, Warrington AP, Tait DM. Volumetric modulated arc therapy planning for distal oesophageal malignancies. Br J Radiol. 2012;85:44–52.CrossRefGoogle Scholar
  29. 29.
    Lin SH, Zhang N, Godby J, Wang J, Marsh GD, Liao Z, et al. Radiation modality use and cardiopulmonary mortality risk in elderly patients with esophageal cancer. Cancer. 2016;122:917–28.CrossRefGoogle Scholar
  30. 30.
    Kwa SL, Lebesque JV, Theuws JC, Marks LB, Munley MT, Bentel G, et al. Radiation pneumonitis as a function of mean lung dose: an analysis of pooled data of 540 patients. Int J Radiat Oncol Biol Phys. 1998;42:1–9.CrossRefGoogle Scholar
  31. 31.
    Lee HK, Vaporcyan AA, Cox JD, Tucker SL, Putman JB Jr, Ajani JA, et al. Postoperative pulmonary complications after preoperative chemoradiation for esophageal carcinoma: correlation with pulmonary dose-volume histograms. Int J Radiat Oncol Biol Phys. 2003;57:1317–22.CrossRefGoogle Scholar
  32. 32.
    Fiandra C, Filippi AR, Catuzzo P, Botticella A, Ciammella A, Franco P, et al. Different IMRT solutions vs 3D-conformal radiotherapy in early stage Hodgkin’s lymphoma: dosimetric comparison and clinical considerations. Radiat Oncol. 2012;7:186.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Stefania Martini
    • 1
  • Francesca Arcadipane
    • 1
  • Paolo Strignano
    • 2
  • Rosella Spadi
    • 3
  • Viviana Contu
    • 4
  • Christian Fiandra
    • 1
  • Riccardo Ragona
    • 1
  • Giorgia Catalano
    • 2
  • Maria Antonietta Satolli
    • 5
  • Michele Camandona
    • 6
  • Renato Romagnoli
    • 2
  • Umberto Ricardi
    • 1
  • Pierfrancesco Franco
    • 1
    • 7
    Email author
  1. 1.Department of Oncology, Radiation OncologyUniversity of TurinTurinItaly
  2. 2.Department of Surgery, General Surgery 2U and Liver Transplantation CenterUniversity of Turin, AOU Citta’ della Salute e della ScienzaTurinItaly
  3. 3.Department of Oncology, Medical Oncology 1AOU Citta’ della Salute e della ScienzaTurinItaly
  4. 4.Department of Oncology, Medical Oncology 2AOU Citta’ della Salute e della ScienzaTurinItaly
  5. 5.Department of Oncology, Medical Oncology 1University of TorinoTurinItaly
  6. 6.Department of Surgical SciencesUniversity of TurinTurinItaly
  7. 7.Department of Oncology – Radiation OncologyUniversity of Turin School of MedicineTurinItaly

Personalised recommendations