14
Submission Packet
Statements
Purpose Statement: The purpose of this study is to compare
plan isocenter locations to determine if a guideline can be
established to prevent collisions of the gantry head with the
immobilization device in all directions while maintaining quality
treatment plans.
Problem Statement: The problem is that prone breast set ups
occasionally result in collisions of the gantry head with the
immobilization device depending on the isocenter location, which
can negatively impact treatment and patient experience.
Hypotheses:
H1A: The research hypothesis (H1) is that an isocenter
location guideline can be developed to prevent collisions with the
prone breast immobilization and gantry head, while still creating a
clinically acceptable treatment plan.
H10: The null hypothesis (H0) is that a guideline isocenter
location cannot be developed that will prevent collisions and
create a clinically acceptable plan.
Change Matrix
Title of Capstone: Minimizing clearance issues with prone
breast patients on Varian linear accelerators through isocenter
placement.
Group: Lauren Wilson & Rob Rohe
Reviewer’s recommendation
How addressed
Page numbers where change appears
Combining these 2 sentences would make for a stronger
introductory statement.
Combined sentences
page 8, intro 1st paragraph
When treating breast cancer, the volume being treated is
often the whole breast, not the "tumor", which has often already
been excised. "Target volume" might be a more appropriate
descrition with some discussion about what the target volume
includes.
Changed verbiage to include “target” volume and elaborated
by saying this is typically the whole breast
page 8, intro 1st paragraph
These 2 sentences seem out of place in this paragraph. The
paragraph is about immobilization, not image guidance. Either you
need a paragraph about image guidance or omit image guidance info
all together.
Are you saying that only lt sided patients have set up errors
and therefore are allowed more imaging dose while rt sided patients
always set up perfectly and therefore don't need imaging? That
makes no sense.
After further review the sentences on image guidance were
deemed unnecessary and were removed
page 8, intro 2nd paragraph
This sentence seems out of place here. You're talking
about reproducibility in this paragraph and then all of a sudden
throw a sentence in about increased complexity of treatment
delivery and the risk of collision. Again, the next paragraph talks
about collision in the first sentence, so this sentence may be
better served there.
Better transition sentence used
page 8, intro 2nd paragraph
What do you mean by "MLC failure with the use of photon
blocks"? This sentence doesn't make sense to me.
Removed part about MLC failure since it seemed irrelevant.
Combined sentenced about clearance of MLC
page 9, intro 3rd paragraph
This section starts stating that you already have
potential resolution to collision issues, then you state that you
have collision issues. I'd potentially rework this a little. Start
with the problem...The problem is that prone breast set ups result
in collision. Nguyen suggested supplemental cameras may help see
collisions when they happen, but don't help avoid them from
happening in the first place. They also suggest the use of as SSD
100 to give additional clearance, but this requires extra set up
time as the treatment is no longer isocentric (something like
that).
Reorganized the paragraph to flow better. First stated the
problem, then the potential solutions and why they don’t cover all
issues
page 9, intro 3rd paragraph
Move sentence to the last paragraph of your intro.
Moved to end of last paragraph of intro
page 9, intro 3rd paragraph
This looks like the declarative statement for what you're
writing your paper about. It should be much stronger and more
clearly stated....The goal of this paper is/was to evaluate the
development of guidelines for isocenter location that would prevent
collision....something like that.
Statement more clearly stated and intent declared
Page 9, intro 4th paragraph
Need a hypothesis abbreviation listed according to the
example.
H1 and H0 added
Page 9, intro 4th paragraph
Inappropriate word choice here
Changed sentence structure and removed word
Page 9, intro 4th paragraph
Reference issues: numbers not in Times New Roman size 12 font,
spacing, italics for journal abbreviation, missing doi
Style corrections to references made, doi added
Page 10, references
To me this sentence reads...Further (as in we need additional)
immobilization is key.....Maybe just say that proper immobilization
of the patient is key to set up reproducibility....
Changed to “proper”
Page 10, intro 2nd paragraph
Font Times New Roman
Header font changed
Page 1
This is your introduction, not your conclusion. I'd start this
out with something more like Currently no guidelines exist....
Changed verbiage to “currently”
Page 10, intro 3rd paragraph
It was decided to remove the null hypothesis statements during
this last draft review.
Removed null hypothesis
Page 10, 4th paragraph
Above you stated that seventeen patients were chosen for the
study. These numbers only add up to 10 patients, 5 Lt sided and 5
rt sided. Where are the other 7 patients?
Changed to 12 RT sided patients
Page 10, methods 1st paragraph
Do you need a section for contouring critical structures?
We discussed this and decided it was not relevant for our
topic
Page 11, methods 3rd paragraph
This reads poorly to me. I'd say something more like,
"...objectives from the institution as described below."
Suggestion made
Page 11, methods 4th paragraph
Do you really have a volume of a volume? Would it be more
accurate to say, at least 95% of the clinical target volume at the
prescription dose, a maximum of 118% of the CTV at 118% of the
prescription dose....
This was a typo. Fixed
Page 11, methods, 4th paragraph
Is it 20Gy or 16Gy to 5% of the heart?
20Gy, 16Gy taken out
Page 11, methods, 4th paragraph
By this point in the paper I'm totally confused. No where are
you talking about or addressing the potential for collision. you're
just talking about plan evaluation and comparison. Do the plans you
are compaing still have the potential for collision? At this point
I don't know.
More details about isocenter shifts/measurements added.
Page 11, methods 3rd paragraph
Need to explain potential for collision in new plans/if
potential for collision still exists
Measurements for collision avoidance outlined.
Page 12, methods 4th paragraph
Format on references last number & take period away after
DOI
Last number corrected and periods removed
Page 13, references
Page Break
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Submission Date:
6/9/2020
Submission Date:
7/3/2020
Submission Date:
7/23/2020
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Minimizing clearance issues with prone breast patients on Varian
linear accelerators through isocenter placement
Lauren Wilson; Rob Rohe, BS, R.T.(T)
Medical Dosimetry Program at the University of Wisconsin-La
Crosse, WI
ABSTRACT
Keywords:
Introduction
The conventional breast radiation treatment technique is
executed with the patient in the supine position, however, some
evidence indicates that radiation treatment delivered in the prone
position is beneficial in order to decrease excess dose delivered
to the lung and heart.1 The intent of prone breast treatment plans
is to provide sufficient coverage to the target volume, typically
the whole breast, while avoiding the inclusion of the lungs and
heart in the treatment field. The prone breast position allows for
increased target coverage and better sparing of the heart, thyroid,
esophagus and contralateral breast and lung in contrast to supine
irradiation treatments.2 Prone breast setups are known to be
particularly helpful in women with large breast size due to the
displacement of the breast from the chest wall and infra-mammary
fold, which often develop skin toxicities from supine breast
treatments.3 The prone set up technique enables improvement of dose
conformity and dose-volume parameters associated with toxicities
but poses new challenges for set up reproducibility.4
A study by Huppert et al5 showed treatment position replication
was challenging for prone breast irradiation and that
immobilization devices are crucial to ensuring accurate positioning
of the patient. The setup can be managed by use of a prone breast
board placed on the patient positioning system, which aligns the
patient in an “arms-up” position and can be made more comfortable
with the addition of a memory foam mattress or Vac-Lok.4 The Civco
Horizon is a prone breast board model that includes scale rulers
and setup sheets to assist with reproducibility (Figure 1 & 2).
A study by Lakosi et al6 analyzed a sample of patients who received
whole breast irradiation in the prone position for patient
satisfaction and reproducibility. The results indicated that set-up
accuracy was comparable with other prone systems and average
patient satisfaction was reported as good.6 Proper immobilization
is key to set up reproducibility in prone breast irradtion.7
Although immobilization devices are necessary for the setup and
reproducibility of prone breast patients, they can occasionally
cause collision issues with the linear accelerator (Figure 3 &
4).8 According to Nguyen et al,7 the addition of supplemental
live-view cameras can help reduce the risk of collision but cannot
keep collisions from occurring. Varian linear accelerators have a
tertiary collimation system with multi-leaf collimators (MLC)
located beneath the X and Y Jaws.9 The tertiary MLC system
decreases the distance from the head of the gantry to the isocenter
which can lead to clearance issues pertaining to the head of the
gantry and the patient or patient positioning system.9 Isocenter
location can contribute to additional clearance issues in Varian
linear accelerators.10 The use of source to skin distance (SSD) of
100 cm may help to provide sufficient clearance for certain prone
breast treatments, but the treatment will no longer be isocentric
and set-up time is increased.6
Currently, no guidelines exist to determine appropriate
isocenter placement and assure collisions do not occur while
treating prone breast patients in radiation therapy. The problem is
that prone breast set ups occasionally result in collisions of the
gantry head with the immobilization device depending on the
isocenter location, which can negatively impact treatment and
patient experience. The goal of this study was to compare plan
isocenter locations to determine if a guideline can be established
to prevent collisions of the gantry head with the immobilization
device in all directions while maintaining quality treatment plans.
The researchers hypothesized that (H1A) an isocenter location
guideline could be developed to prevent collisions with the prone
breast immobilization and gantry head, while still creating a
clinically acceptable treatment plan.
Methods and Materials
Patient Selection & Setup
Seventeen patients from a single institution were chosen for
this study. The inclusion criteria were female patients with left
or right-sided breast cancer, treated using 3D conformal treatment
technique with tangential fields in the prone position. Patients
with regional lymph node involvement were excluded from this study.
The patient data was collected retrospectively to include 5
patients with left-sided breast cancer and 12 patients with
right-sided breast cancer. Fractionation and prescription doses
varied amongst patients but all patients were treated with a
curative intent and with a mix of 6 MV and 10 MV energies,
dependent on the size of the patient and planning restrictions at
the institution. Any isocenter shifts from boost plans were not
included in the final comparison.
All patients were simulated on a Philips CT scanner using slice
thickness of 2 mm for the scan. Patients were positioned head first
with both arms above the head in the prone position (Figure 5). For
simulation, the physician placed wire around the breast tissue to
mark landmarks for contouring. The scan was exported to the
RayStation (Version 8A SP1) treatment planning system (TPS).
Isocenter Location
Prior to planning, a clearance threshold was developed using
patient positioning system locations relative to isocenter to
ensure safe treatment of patients with the Civco Horizon
immobilization on Varian Truebeam linear accelerator. The isocenter
location threshold was measured to be within 6 cm mediolaterally of
midline and less than or equal to 16 cm from the top of the patient
position system. Superior and inferior shifts were determined to
not be a cause of concern regarding collision issues with prone
breast patients, but were used at times due to the field size
limitations in prone breast planning. Isocenters located in above
range were found to allow for clearance on the Varian Truebeam
linear accelerator in regards to the patient immobilization and
patient positioning system. After a new isocenter location was
determined for each patient, a new treatment plan was created
following the clinical objectives from the institution, which are
described below.
Objectives
Objectives that had to be achieved following isocenter shifts
included no more than 95% of the clinical target volume (CTV) at
the prescription dose, no more than 30% volume of CTV at 118% of
prescription dose, and no more than 50% volume of CTV at 112% of
prescription dose. In addition, no more than 400 cGy average dose
of the heart and no more than 2000 cGy dose at 5% volume of the
heart. For the lungs, objectives were set for no more than 55%
volume of the right lung at 400 cGy dose, and no more than 15%
volume of the left lung at 400 cGy dose. These organs at risk (OAR)
constraints followed the Radiation Therapy Oncology Group (RTOG)
1005 constraints and institution guidelines. The plan doses for the
OAR objectives and volumes were documented for the initial plans
and re-plans after isocenter shifts.
Plan Comparison
The evaluated metrics for this study involved the isocenter,
OAR, and target volumes. Isocenter shifts from the original plan
were generated and data from all plans was averaged. The new plan
OAR data was statistically evaluated compared to the original plans
to help determine if the new treatment plans were clinically
acceptable. The new isocenter was evaluated based on its location
relative to the previous plan isocenter and whether the new
location was within the clearance threshold of plus or minus 6 cm
medially/laterally from midline and within 16 cm from the top of
the patient positioning system. Next, the OAR were examined
specifically looking at the mean lung dose, D95 heart dose, D1
heart dose, D95 lung dose, and D1 lung dose. These parameters were
intended to meet RTOG 1005 constraints and the percent difference
from the original plan for D95, D1 and mean dose were recorded for
the lungs and heart. The planning target volume (PTV) doses from
each re-plan was evaluated based on percent of PTV receiving 90%,
95% and 100% of the prescribed dose. The PTV dose objectives must
have been within 3% difference of the original plan.
Statistical Analysis
Each patient plan was evaluated individually for data
collection. The data were statistically evaluated for normality
using the Shapiro-Wilk test. In addition, the Wilcoxon Signed Rank
test (WSR) was used for all OAR and target metrics, including the
mean heart dose, mean lung dose, D95 heart dose, D95 lung dose, D1
heart dose, and D1 lung dose. In addition the WSR was performed on
the PTV for percent volume receiving 90%, 95% and 100% of the
prescribed dose. For each of the OARs evaluated, Wilcoxon signed
rank tests were performed to compare the distributions for the new
isocenter compared to the original isocenter. Data was collected
for Lungs D95 (cGy) but no hypothesis testing was needed because
all of the measured values for both treatment plans were 0, thus
showing no difference between treatment isocenters.
The Benjamini-Hochberg adjustment, or false discovery rate, was
applied to control the type 1 error rate for multiple testing with
a family-wise error rate of 5% for the 17 tests overall.11 Each
sample of differences was examined for normality both graphically
and with Shapiro-Wilk normality tests. It was determined that
Wilcoxon signed rank tests were preferable to paired t-tests due to
non-normality observed in several of the samples.
Results
Objectives
The WSR test was performed to investigate the relationship
between OAR metrics of original and new plans. A positive
difference indicated that the dose using the new isocenter was
higher than the dose for the original isocenter and a negative
difference indicated that the dose for the new isocenter was less
than the dose for the original isocenter (Table 1). Only one OAR
objective registered a statistically significant difference in the
median dose for the population of all patients under the new and
original isocenter. The population median dose for CTV Breast D95
was higher in using the new isocenter (Padj = 0.034) and no
statistically significant differences were found for the median
doses for CTV Breast Mean or D1. No significant differences in
population medians were seen in any of the remaining 16 OARs tested
(all Padj > 0.05). The non-parametric related samples evaluated
by the WSR test revealed no statistically significant differences
for Heart Mean D95 and D1. In addition, no statistically
significant differences were calculated in the median dose for the
Lung Mean and D1.
The WSR test evaluated the relationship between target volumes
of original and new plans. The population median doses for PTV D95,
PTV Mean, CTV D95, CTV Mean, CTV D1 and GTV D95 revealed a positive
difference indicating that the dose using the new isocenter was
higher than the dose for the original isocenter. The population
median doses for PTV D1, GTV Mean and GTV D1 revealed a negative
difference indicating that the dose for the new isocenter was less
than the dose for the original isocenter. No metrics registered a
statistically significant difference in the median dose for the
population of all patients under the new and original isocenter
(all Padj > 0.05).
Isocenter Location
No original plan isocenter fell into clearance threshold and all
isocenters from new plans were located within clearance threshold
metrics defined as within 6 cm mediolaterally of midline and less
than or equal to 16 cm from the top of the patient position system
(Table 2). Superior and inferior shifts were not considered to
contribute to collisions. The average isocenter shift from the
original plan to acceptable parameters measured 3.28 cm medially
and 3.1 cm anterior.
Discussion
Conclusion
I would like to thank the Statistical Consulting Center at UW-La
Crosse for its assistance with statistical analysis; however, any
errors of fact or interpretation remain the sole responsibility of
the author.
References
1. Yao S, Zhang Y, Nie K, et al. Setup uncertainties and the
optimal imaging schedule in the prone position whole breast
radiotherapy. Radiat Oncol. 2019;14(1):76.
https://doi.org/10.1186/s13014-019-1282-4
2. Deseyne P, Speleers B, De Neve W, et al. Whole breast and
regional nodal irradiation in prone versus supine position in left
sided breast cancer. Radiat Oncol. 2017;12(1):89.
https://doi.org/10.1186/s13014-017-0828-6
3. Boyages J, Baker L. Evolution of radiotherapy techniques in
breast conservation treatment. Gland Surg. 2018;7(6):576-595.
https://doi.org/10.21037/gs.2018.11.10
4. Fahimian B, Yu V, Horst K, Xing L, Hristov D. Trajectory
modulated prone breast irradiation: A LINAC-based technique
combining intensity modulated delivery and motion of the couch.
Radiother Oncol. 2013;109(3):475-481.
https://doi:10.1016/j.radonc.2013.10.031
5. Huppert N, Jozsef G, Dewyngaert K, Formenti SC. The role of a
prone setup in breast radiation therapy. Front Oncol. 2011;1:1-8.
https://doi.org/10.3389/fonc.2011.00031
6. Lakosi F, Gulyban A, Ben-Mustapha Simoni S, et al.
Feasibility evaluation of prone breast irradiation with the
Sagittilt system including residual-intrafractional error
assessment. Cancer Radiother. 2016;20(8):776
782.https://doi.org/10.1016/j.canrad.2016.05.014
7. Nguyen SM, Chlebik AA, Olch AJ, Wong KK. Collision risk
mitigation of varian TrueBeam linear accelerator with supplemental
live-view cameras. Prac Radiat Oncol. 2019;9(1):e103-e109.
https://doi.org/10.1016/j.prro.2018.07.001
8. Gupta A, Ohri N, Haffty B. Hypofractionated radiation
treatment in the management of breast cancer. Expert Rev Anticancer
Ther. 2018;18(8):793-803.
https://doi.org/10.1080/14737140.2018.1489245
9. Mohan R, Jayesh K, Joshi R, Al-idrisi M, Narayanamurthy P,
Majumdar SK. Dosimetric evaluation of 120-leaf mulileaf collimator
in a Varian linear accelerator with 6-MV and 18-MV photon beams. J
Med Phys. 2008;33(3):114-118.
https://doi.org/10.4103/0971-6203.42757
10. Boyer A, Biggs P, Gavin J, et al. AAPM report 72: basic
applications of multileaf collimators. Madison, WI: Medical Physics
Publishing, American Association of Physicists in Medicine;
2001.
11. Benjamini Y, Hochberg Y. Controlling the False Discovery
Rate: A Practical and Powerful Approach to Multiple Testing.
Journal of the Royal Statistical Society: Series B
(Methodological). 1995;57(1):289-300.
https://doi.org/10.1111/j.2517-6161.1995.tb02031.x
Figures
Figure 1. Civco Horizon prone breast board for prone breast
treatment immobilization.
Figure 2. Civco Horizon prone breast board for prone breast
treatment immobilization.
Figure 3. Civco Horizon prone breast board collision with Varian
gantry head.
Figure 4. Civco Horizon prone breast board collision with Varian
gantry head.
Figure 5. Philips CT (computed tomography) machine with Civco
Horizon prone breast board for prone breast simulation.
Table 1. 95% confidence intervals for medians and FDR-adjusted
Wilcoxon signed rank P-values for the mean difference are given for
each OAR.
95% CI
Response
Padj
Lower
Upper
CTV Breast D95 (cGy)
0.034*
21.5
73.5
CTV Breast Mean (cGy)
0.561
-1.5
18.5
CTV Breast D1 (cGy)
1.000
-15.5
21.0
PTV TumorBed D95 (cGy)
1.000
-16.5
18.0
PTV TumorBed Mean (cGy)
1.000
-10.0
13.5
PTV TumorBed D1 (cGy)
0.561
-5.5
24.5
CTV TumorBed D95 (cGy)
0.924
-16.5
11.5
CTV TumorBed Mean (cGy)
1.000
-10.0
10.0
CTV TumorBed D1 (cGy)
1.000
-11.0
20.0
GTV TumorBed D95 (cGy)
1.000
-16.0
25.0
GTV TumorBed Mean (cGy)
1.000
-10.5
16.0
GTV TumorBed D1 (cGy)
1.000
-18.5
24.0
Heart D95 (cGy)
0.561
-0.5
5.0
Heart Mean (cGy)
0.561
-1.0
7.5
Heart D1 (cGy)
0.561
-11.0
21.0
Lungs Mean (cGy)
1.000
-3.5
3.0
Lungs D1 (cGy)
0.799
-33.5
53.0
*Significantly different at the 5% level
Table 2. Isocenter locations and shifts from original plan
isocenter to isocenter location within clearance threshold.
Plan ID
Isocenter Location from Midline (cm)
From top of PPS (cm)
Isocenter Shifts Medially (cm)
Isocenter Shifts Anteriorly (cm)
1
5.98
14.92
6
3
2
5.51
14.98
1
4.5
3
5.04
14.93
2
3
4
5
16
2
4
5
5.74
14.89
3.76
3.11
6
5.98
14.89
5.52
3.11
7
5.98
14.95
3.02
2.05
8
5.98
15.11
5.02
5.39
9
6
15
5.5
3.5
10
6
15
3
2.5
11
6
15
7
4
12
6
15
2
3
13
6
15
3
6
14
6
15
5
2.5
15
5
15
0
1.1
16
4.5
15
0
2
17
6
15
2
0
Average:
3.28
3.1
