Quantification and Minimization of Uncertainties of Internal Target Volume for Stereotactic Body Radiation Therapy of Lung Cancer

Abstract

To quantify uncertainties in delineating an internal target volume (ITV) and to understand how these uncertainties may be individually minimized for stereotactic body radiation therapy (SBRT) of early stage non-small cell lung cancer (NSCLC). Twenty patients with NSCLC who were undergoing SBRT were imaged with free-breathing 3-dimensional computed tomography (3DCT) and 10-phase 4-dimensional CT (4DCT) for delineating gross tumor volume (GTV)(3D) and ITV(10Phase) (ITV3). The maximum intensity projection (MIP) CT was also calculated from 10-phase 4DCT for contouring ITV(MIP) (ITV1). Then, ITV(COMB) (ITV2), ITV(10Phase+GTV3D) (ITV4), and ITV(10Phase+ITVCOMB) (ITV5) were generated by combining ITV(MIP) and GTV(3D), ITV(10phase) and GTV(3D), and ITV(10phase) and ITV(COMB), respectively. All 6 volumes (GTV(3D) and ITV1 to ITV5) were delineated in the same lung window by the same radiation oncologist. The percentage of volume difference (PVD) between any 2 different volumes was determined and was correlated to effective tumor diameter (ETD), tumor motion ranges, R(3D), and the amplitude variability of the recorded breathing signal (v) to assess their volume variations. The mean (range) tumor motion (R(SI), R(AP), R(ML), and R(3D)) and breathing variability (v) were 7.6 mm (2-18 mm), 4.0 mm (2-8 mm), 3.3 mm (0-7.5 mm), 9.9 mm (4.1-18.7 mm), and 0.17 (0.07-0.37), respectively. The trend of volume variation was GTV(3D) <ITV1 <ITV2 ≈ ITV3 < ITV4 < ITV5. The means ± SDs of these volumes were 11.1 ± 9.3 cc, 13.2 ± 10.5 cc, 14.9 ± 11.0 cc, 14.7 ± 11.4 cc, 15.9 ± 11.7 cc, and 16.4 ± 11.8 cc, respectively. All comparisons between the target volumes showed statistical significance (P≤.001), except for ITV2 and ITV3 (P=.594). The PVDs for all volume pairs correlated negatively with ETD (r≤-0.658, P≤.006) and positively with R(3D) (r≥0.503, P≤.047). The PVDs for pairs of ITV2 vs ITV5 and ITV5 vs ITV4 negatively correlated with ETD (r=0.502, -0.626; P=.047, .010). No other correlation was found. Uncertainties in individualized ITVs for SBRT of early stage NSCLC could effectively be minimized by combining information from 3DCT, 4DCT, and MIP. If these images cannot be efficiently contoured, a combination of ITV(MIP) and GTV(3D) could be an effective alternative.