Information gained from 4D planning imaging studies can aid in designing radiotherapy treatments with reduced normal tissue irradiation for patients with thoracic lesions. With this 4D approach, conventional portal verification techniques will not provide sufficient information for treatment verification. We have developed an online portal verification tool for use with 4D-planned radiotherapy. The purpose of this study is to evaluate the efficacy of 4D portal verification for adaptive radiotherapy for lung cancer. Our approach for respiratory compensation is to treat a target located at the mean respiratory position of the primary tumor, and to optimize the dose distribution to best compensate for the random motion determined from pretreatment 4D CT and fluoroscopy. One prerequisite for such a technique is that tumor motion due to respiration is stable both inter- and intrafraction. The mean position and standard deviation provide criteria for determining the stability. Instability can be compensated either in planning by increasing margins or daily by online correction. In either case, the stability must be verified daily by measuring the mean position and standard deviation. To evaluate the clinical feasibility of daily portal verification, digital fluoroscopy was acquired at two orthogonal projections for 5 patients using an Elekta Synergy (Crawley, UK) accelerator equipped with onboard x-ray volumetric imaging (XVI). Our online portal verification tool was used to generate a respiratory curve from each fluoroscopic study by automatically extracting the diaphragm position in relation to the beam isocenter as a function of time. This respiratory trace was used to generate a probability density function of diaphragm position, and the mean and standard deviation of the position were calculated. Fluoroscopy was acquired once weekly for each patient during treatment. The mean and standard deviation for each weekly fluoroscopic study were compared to the simulation study. Patient-specific margin size as a function of probability of a required daily correction was calculated. A dose profile along the cranio-caudal axis from the clinical treatment plan of each patient was convolved with the probability density function from the simulation fluoroscopy to generate a patient-specific deterministic margin. The deterministic margin accounts for motion-induced effects on the dose distribution without considering the possibility of changes to a patient’s respiration over the course of treatment. A stochastic component of the margin was then generated assuming such uncertainty, and the total margin consisted of the sum of the deterministic and stochastic components. Patient-specific margins were generated (table 1) for probabilities of required daily correction of 5%, 10%, 25%, and 45% of total treatments. Deterministic margins ranged from 0.0 to 2.1 mm, while stochastic margins ranged from 1.7 to 4.7 mm. The average stochastic margins for 5%, 10%, 25%, and 45% were 4.6 mm, 4.0 mm, 3.1 mm, and 2.3 mm, respectively. Total margin for 10% correction probability ranged from 3.5 mm to 6.2 mm. Online portal verification for adaptive radiotherapy for lung cancer must include components to verify not only static positioning, but also the dynamic aspects involving tumor motion. For treatment at the mean tumor position, verification of the stability of the mean and standard deviation of the tumor position allows an assessment of the necessity of online correction to be made. For this study, the total population margin due to respiratory motion could be limited to 6.2 mm allowing for setup corrections 10% of the time.
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