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Lung Lab Discussion

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30 views

Lung Lab Discussion

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api-691667702
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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I chose the topic of respiratory motion in treatment planning as I have spent five years researching this

area and I wish to share my expertise with my peers. In this post, I will focus on two main concepts: the
effect of respiratory motion on imaging and treatment delivery, and the methods used to mitigate these
effects.
Respiratory motion in lung cancer patients has been found to extend up to 50mm in the superior-
inferior direction.1 This motion is particularly notable in the diaphragm region. Patient movement during
image acquisition is recognized to induce image artifacts, resulting in an inaccurate depiction of the
patient's anatomy and density. Consequently, errors in treatment planning occur as the delineation of
tumors and organs at risk (OARs) is compromised.2 Figure 1 illustrates the impact of breathing motion on
imaging.

Figure 1: Various examples of image artifacts caused by breathing motion: a) Blurring of the right
diaphragmatic dome and overlapping of structures, b) Blurring of the lower part of the tumor, and c)
Replicated structures alongside blurring of the tumor.3
1. Effects of respiratory motion on imaging and treatment delivery
There are three primary effects of respiratory motion on treatment delivery: dose deformations, dose
blurring, and interplay effects. Dose deformations refer to secondary motion effects occurring due to
variations in dose distribution caused by displacement and deformation of internal anatomy. Dose
blurring leads to the widening of the beam penumbra, reducing the conformity of the dose distribution
(Figure 2).4 Interplay effects are unique to dynamic beam delivery techniques such as IMRT, enhanced
dynamic wedge (EDW), and tomotherapy. If the tumor and the multileaf collimators (MLCs) are both in
motion during treatment delivery, the MLCs may block the beam at the target, which results in
underdosing of the target and overdosing of healthy tissue.
Figure 2: Dose profiles illustrating the blurring effect caused by motion. The dashed line represents the
dose profile of a static target, while the solid lines depict the dose profile of a moving target. As depicted
in this figure, when the tumor is in motion, it tends to be underdosed at the periphery, while the
surrounding tissue is overdosed.
2. Methods used to mitigate respiratory motion in radiation therapy:
Respiratory motion management becomes necessary when the target's motion exceeds 5mm. The
suitability of any motion management method depends on the patient's tolerance and its ability to
enhance sparing of normal tissue. These techniques can be applied either during the planning or
delivery stages of treatment.1
As previously mentioned, respiratory motion during imaging can result in motion artifacts. To mitigate
this, CT images can be acquired while the patient holds their breath. Additionally, techniques such as
4DCT and gated CT can minimize these artifacts, with a scan time requirement of less than 19.1 msec to
prevent artifacts.5
From the perspectives of treatment planning and treatment delivery, four primary methods for
managing respiratory motion are employed: the margin approach, breath hold, gating, and tumor
tracking, along with the mid-ventilation approach.

2.1: Margin approach


The predominant method for addressing respiratory motion in treatment planning involves
incorporating an extra margin around the target volume. Figure 3 illustrates the Gross Tumor Volume
(GTV), Clinical Target Volume (CTV), Internal Target Volume (ITV), and Planning Target Volume (PTV).
The ITV is generated by merging CTV contours at both inhale and exhale phases. While this strategy
ensures coverage of moving structures, it tends to be overly cautious, assuming uniform tumor duration
across respiratory phases. Consequently, using margin approach often leads to a larger volume of
healthy lung tissue receiving irradiation compared to alternative respiratory motion management
techniques.
Figure 3: A schematic showing the GTV, CTV, ITV and PTV. Per ICRU62 report 6, the GTV is the gross
target volume that is visible in a CT scan. A margin is added around the GTV to account for microscopic
disease. The GTV with the added margin is known as the clinical target volume (CTV). The volume that
encompasses the motion range of the CTV is known as the internal target volume (ITV). A margin is then
added to the ITV to account for setup uncertainties. The ITV with the added margin forms the planning
target volume (PTV). In the margin approach mentioned in section 2.1, The PTV is the target structure.

2.2: Breath hold


This technique involves maintaining the tumor position stationary by having the patient hold their
breath during treatment delivery. However, this method is only viable if the patient can sustain a breath
hold for at least 10 seconds. 7 Its safe implementation necessitates patient training and guidance during
treatment, often facilitated through audiovisual feedback or similar devices. Monitoring the patient's
ability to maintain breath hold can be achieved via spirometry 8,9, external markers10, or imaging of
implanted fiducials.11
Treatment is typically administered at either end-inhalation or end-exhalation. Deep inspiration breath
hold (DIBH) is preferred due to reduced lung density, which can decrease the dose to the heart. At our
clinic at VCU, we routinely utilize the DIBH technique for treating breast cancer patients, particularly
those with left-sided breast cancer.
2.3: Gating
Gated radiation therapy involves delivering radiation exclusively during a precise phase of the
respiratory cycle. Unlike the breath hold technique, it offers an advantage for patients with
compromised pulmonary function, as they can tolerate it more effectively. Research has demonstrated
that gated radiation therapy can diminish treatment margins, particularly for tumors with substantial
mobility.12 However, one drawback of this approach is decreased treatment efficiency, as the beam is
activated for only a portion of the respiratory cycle. Consequently, a combined technique incorporating
Deep Inspiration Breath Hold (DIBH) and gated radiation therapy may be preferable if the patient can
tolerate it.13
2.4: Tumor tracking
In tumor tracking, respiratory motion is managed by aligning the radiation beam's movement with the
trajectory of the tumor's motion. This synchronization can be achieved through dynamic motion of
multileaf collimators (MLCs) or by employing a robotic couch. 14 Another method involves using the
CyberKnife system, a compact linac mounted on a robotic arm, for tracking purposes.
Typically, an external marker is utilized to track the internal motion of the tumor and synchronize MLC
leaf motion with the target's movement. However, an internal fiducial marker is generally preferred.
Safety measures include pausing the beam if significant disparities emerge between the planned and
measured tumor trajectories. Additionally, providing patients with breathing guidance is crucial for
enhancing the accuracy of dynamic MLC treatment delivery. 15 In my experience, I have observed limited
utilization of tumor tracking in clinical settings. This approach primarily remains a subject of research
rather than widespread clinical application.

References:

1. Keall PJ, Mageras GS, Balter JM, et al. The management of respiratory motion in radiation oncology
report of AAPM Task Group 76. Med Phys. 2006;33(10):3874-3900. doi:10.1118/1.2349696

2. Gagné IM, Robinson DM. The impact of tumor motion upon CT image integrity and target
delineation. Med Phys. 2004;31(12):3378-3392. doi:10.1118/1.1799291

3. Korreman SS. Motion in radiotherapy: photon therapy. Phys Med Biol. 2012;57(23):R161-R191.
doi:10.1088/0031-9155/57/23/R161

4. Bortfeld T, Jiang SB, Rietzel E. Effects of motion on the total dose distribution. Semin Radiat Oncol.
2004;14(1):41-51. doi:10.1053/j.semradonc.2003.10.011

5. Ritchie CJ, Godwin JD, Crawford CR, Stanford W, Anno H, Kim Y. Minimum scan speeds for suppression
of motion artifacts in CT. Radiology. 1992;185(1):37-42. doi:10.1148/radiology.185.1.1523332

6. Purdy JA. Current ICRU definitions of volumes: limitations and future directions. Semin Radiat Oncol.
2004;14(1):27-40. doi:10.1053/j.semradonc.2003.12.002

7. Hanley J, Debois MM, Mah D, et al. Deep inspiration breath-hold technique for lung tumors: the
potential value of target immobilization and reduced lung density in dose escalation. Int J Radiat Oncol
Biol Phys. 1999;45(3):603-611. doi:10.1016/s0360-3016(99)00154-6

8. Rosenzweig KE, Hanley J, Mah D, et al. The deep inspiration breath-hold technique in the treatment of
inoperable non-small-cell lung cancer. Int J Radiat Oncol Biol Phys. 2000;48(1):81-87. doi:10.1016/s0360-
3016(00)00583-6

9. Mah D, Hanley J, Rosenzweig KE, et al. Technical aspects of the deep inspiration breath-hold technique
in the treatment of thoracic cancer. Int J Radiat Oncol Biol Phys. 2000;48(4):1175-1185.
doi:10.1016/s0360-3016(00)00747-1
10. Stock M, Kontrisova K, Dieckmann K, Bogner J, Poetter R, Georg D. Development and application of a
real-time monitoring and feedback system for deep inspiration breath hold based on external marker
tracking. Med Phys. 2006;33(8):2868-2877. doi:10.1118/1.2219775

11. Murphy MJ, Martin D, Whyte R, Hai J, Ozhasoglu C, Le QT. The effectiveness of breath-holding to
stabilize lung and pancreas tumors during radiosurgery. Int J Radiat Oncol Biol Phys. 2002;53(2):475-482.
doi:10.1016/s0360-3016(01)02822-x

12. Underberg RW, Lagerwaard FJ, Slotman BJ, Cuijpers JP, Senan S. Benefit of respiration-gated
stereotactic radiotherapy for stage I lung cancer: an analysis of 4DCT datasets. Int J Radiat Oncol Biol
Phys. 2005;62(2):554-560. doi:10.1016/j.ijrobp.2005.01.032

13. Berson AM, Emery R, Rodriguez L, et al. Clinical experience using respiratory gated radiation therapy:
comparison of free-breathing and breath-hold techniques. Int J Radiat Oncol Biol Phys. 2004;60(2):419-
426. doi:10.1016/j.ijrobp.2004.03.037

14. Keall PJ, Cattell H, Pokhrel D, et al. Geometric accuracy of a real-time target tracking system with
dynamic multileaf collimator tracking system. Int J Radiat Oncol Biol Phys. 2006;65(5):1579-1584.
doi:10.1016/j.ijrobp.2006.04.038

15. Neicu T, Berbeco R, Wolfgang J, Jiang SB. Synchronized moving aperture radiation therapy (SMART):
improvement of breathing pattern reproducibility using respiratory coaching. Phys Med Biol.
2006;51(3):617-636. doi:10.1088/0031-9155/51/3/010

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