Respiratory-gated Radiotherapy Research Articles

Respiratory monitoring with an acceleration sensor

Respiratory gating radiotherapy is used to irradiate a local area and to reduce normal tissue toxicity. There are certain methods for the detection of tumor motions, for example, using internal markers or an external respiration signal. However, because some of these respiratory monitoring systems require special or expensive equipment, respiratory monitoring can usually be performed only in limited facilities. In this study, the feasibility of using an acceleration sensor for respiratory monitoring was evaluated. The respiratory motion was represented by means of a platform and measured five times with the iPod touch® at 3, 4 and 5 s periods of five breathing cycles. For these three periods of the reference waveform, the absolute means ± standard deviation (SD) of displacement were 0.45 ± 0.34 mm, 0.33 ± 0.24 mm and 0.31 ± 0.23 mm, respectively. On the other hand, the corresponding absolute means ± SD for the periods were 0.04 ± 0.09 s, 0.04 ± 0.02 s and 0.06 ± 0.04 s. The accuracy of respiratory monitoring using the acceleration sensor was satisfactory in terms of the absolute means ± SD. Using the iPod touch® for respiratory monitoring does not need special equipment and makes respiratory monitoring easier. For these reasons, this system is a viable alternative to other respiratory monitoring systems.

Management of the baseline shift using a new and simple method for respiratory‐gated radiation therapy: Detectability and effectiveness of a flexible monitoring system

In respiratory-gated radiation therapy, a baseline shift decreases the accuracy of target coverage and organs at risk (OAR) sparing. The effectiveness of audio-feedback and audio-visual feedback in correcting the baseline shift in the breathing pattern of the patient has been demonstrated previously. However, the baseline shift derived from the intrafraction motion of the patient's body cannot be corrected by these methods. In the present study, the authors designed and developed a simple and flexible system. The system consisted of a web camera and a computer running our in-house software. The in-house software was adapted to template matching and also to no preimage processing. The system was capable of monitoring the baseline shift in the intrafraction motion of the patient's body. Another marker box was used to monitor the baseline shift due to the flexible setups required of a marker box for gated signals. The system accuracy was evaluated by employing a respiratory motion phantom and was found to be within AAPM Task Group 142 tolerance (positional accuracy <2 mm and temporal accuracy <100 ms) for respiratory-gated radiation therapy. Additionally, the effectiveness of this flexible and independent system in gated treatment was investigated in healthy volunteers, in terms of the results from the differences in the baseline shift detectable between the marker positions, which the authors evaluated statistically. The movement of the marker on the sternum [1.599 +/- 0.622 mm (1 SD)] was substantially decreased as compared with the abdomen [6.547 +/- 0.962 mm (1 SD)]. Additionally, in all of the volunteers, the baseline shifts for the sternum [-0.136 +/- 0.868 (2 SD)] were in better agreement with the nominal baseline shifts than was the case for the abdomen [-0.722 +/- 1.56 mm (2 SD)]. The baseline shifts could be accurately measured and detected using the monitoring system, which could acquire the movement of the marker on the sternum. The baseline shift-monitoring system with the displacement-based methods for highly accurate respiratory-gated treatments should be used to make most of the displacement-based gating methods. The advent of intensity modulated radiation therapy and volumetric modulated radiation therapy facilitates margin reduction for the planning target volumes and the OARs, but highly accurate irradiation is needed to achieve target coverage and OAR sparing with a small margin. The baseline shifts can affect treatment not only with the respiratory gating system but also without the system. Our system can manage the baseline shift and also enables treatment irradiation to be undertaken with high accuracy.

Treatment delivery time optimization of respiratory gated radiation therapy by application of audio-visual feedback

Purpose: Tumor motion management, especially for thoracic tumors, is a particular problem in both delineation of tumors and organs at risk as well as during the actual treatment delivery. The latter will be covered at our department with the introduction of the Novalis ExacTrac (BrainLAB AG, Feldkirchen, Germany) IGRT system for the treatment of lung tumors and liver metastases evolving from motion-encompassing techniques towards respiratory-gated radiation therapy. In order to maintain the accuracy achieved by the implementation of gated treatment delivery, the treatment time should be minimized. The aim of this study was to evaluate the feasibility to optimize and reduce the gated total treatment time delivery by the introduction of voluntary breath-hold with and without audio assistance.

Dynamic gating window for compensation of baseline shift in respiratory‐gated radiation therapy

To analyze and evaluate the necessity and use of dynamic gating techniques for compensation of baseline shift during respiratory-gated radiation therapy of lung tumors. Motion tracking data from 30 lung tumors over 592 treatment fractions were analyzed for baseline shift. The finite state model (FSM) was used to identify the end-of-exhale (EOE) breathing phase throughout each treatment fraction. Using duty cycle as an evaluation metric, several methods of end-of-exhale dynamic gating were compared: An a posteriori ideal gating window, a predictive trend-line-based gating window, and a predictive weighted point-based gating window. These methods were evaluated for each of several gating window types: Superior/inferior (SI) gating, anterior/posterior beam, lateral beam, and 3D gating. In the absence of dynamic gating techniques, SI gating gave a 39.6% duty cycle. The ideal SI gating window yielded a 41.5% duty cycle. The weight-based method of dynamic SI gating yielded a duty cycle of 36.2%. The trend-line-based method yielded a duty cycle of 34.0%. Dynamic gating was not broadly beneficial due to a breakdown of the FSM's ability to identify the EOE phase. When the EOE phase was well defined, dynamic gating showed an improvement over static-window gating.

Patient's Perception of Care Quality During Radiotherapy Sessions Using Respiratory Gating Techniques: Validation of a Specific Questionnaire

This prospective study was designed to validate a questionnaire on patients’ perception of care quality during respiratory-gated radiotherapy for breast or lung cancer. Psychometric tests were performed on selected patients. Confirmatory factorial analyses and capacity to discriminate the responses were achieved to validate the best model on 297 patients. Factorial analyses identified the following three scales: (a) perception of quality, (b) global satisfaction, and (c) physical or emotional experience. The scales were able to differentiate patients’ responses according to radiotherapy modalities. The questionnaire presented adequate psychometric properties. This tool could be used for the assessment from the patient's point of view.

Respiration-gated Radiotherapy in a Large Prospective Lung Cancer Study: Dosimetric and Clinical Benefits

Respiration-gated Radiotherapy in a Large Prospective Lung Cancer Study: Dosimetric and Clinical Benefits

Respiration-gated Radiotherapy in a Large Prospective Breast Cancer Study: Dosimetric and Clinical Benefits

Respiration-gated Radiotherapy in a Large Prospective Breast Cancer Study: Dosimetric and Clinical Benefits

Cardiac and pulmonary dose reduction for tangentially irradiated breast cancer, utilizing deep inspiration breath-hold with audio-visual guidance, without compromising target coverage

Background and purpose. Cardiac disease and pulmonary complications are documented risk factors in tangential breast irradiation. Respiratory gating radiotherapy provides a possibility to substantially reduce cardiopulmonary doses. This CT planning study quantifies the reduction of radiation doses to the heart and lung, using deep inspiration breath-hold (DIBH). Patients and methods. Seventeen patients with early breast cancer, referred for adjuvant radiotherapy, were included. For each patient two CT scans were acquired; the first during free breathing (FB) and the second during DIBH. The scans were monitored by the Varian RPM™ respiratory gating system. Audio coaching and visual feedback (audio-visual guidance) were used. The treatment planning of the two CT studies was performed with conformal tangential fields, focusing on good coverage (V95>98%) of the planning target volume (PTV). Dose-volume histograms were calculated and compared. Doses to the heart, left anterior descending (LAD) coronary artery, ipsilateral lung and the contralateral breast were assessed. Results. Compared to FB, the DIBH-plans obtained lower cardiac and pulmonary doses, with equal coverage of PTV. The average mean heart dose was reduced from 3.7 to 1.7 Gy and the number of patients with >5% heart volume receiving 25 Gy or more was reduced from four to one of the 17 patients. With DIBH the heart was completely out of the beam portals for ten patients, with FB this could not be achieved for any of the 17 patients. The average mean dose to the LAD coronary artery was reduced from 18.1 to 6.4 Gy. The average ipsilateral lung volume receiving more than 20 Gy was reduced from 12.2 to 10.0%. Conclusion. Respiratory gating with DIBH, utilizing audio-visual guidance, reduces cardiac and pulmonary doses for tangentially treated left sided breast cancer patients without compromising the target coverage.

Gating and tracking, 4D in thoracic tumours

The limited ability to control for a tumour's location compromises the accuracy with which radiation can be delivered to tumour-bearing tissue. The resultant requirement for larger treatment volumes to accommodate target uncertainty restricts the radiation dose because more surrounding normal tissue is exposed. With image-guided radiation therapy (IGRT), these volumes can be optimized and tumouricidal doses may be delivered, achieving maximum tumour control with minimal complications. Moreover, with the ability of high precision dose delivery and real-time knowledge of the target volume location, IGRT has initiated the exploration of new indications in radiotherapy such as hypofractionated radiotherapy (or stereotactic body radiotherapy), deliberate inhomogeneous dose distributions coping with tumour heterogeneity (dose painting by numbers and biologically conformal radiation therapy), and adaptive radiotherapy. In short: “individualized radiotherapy”. Tumour motion management, especially for thoracic tumours, is a particular problem in this context both for the delineation of tumours and organs at risk as well as during the actual treatment delivery. The latter will be covered in this paper with some examples based on the experience of the UZ Brussel. With the introduction of the NOVALIS system (BrainLAB, Feldkirchen, Germany) in 2000 and consecutive prototypes of the ExacTrac IGRT system, gradually a hypofractionation treatment protocol was introduced for the treatment of lung tumours and liver metastases evolving from motion-encompassing techniques towards respiratory-gated radiation therapy with audio-visual feedback and most recently dynamic tracking using the VERO system (BrainLAB, Feldkirchen, Germany). This evolution will be used to illustrate the recent developments in this particular field of research.

Effects of breathing variation on gating window internal target volume in respiratory gated radiation therapya)

To investigate the effects of breathing variation on gating window internal target volume (ITVGW) in respiratory gated radiation therapy. Two-dimensional dynamic MRI (dMRI) of lung motion was acquired in ten volunteers and eight lung cancer patients. Resorted dMRI using 4DCT acquisition method (RedCAM) was generated for selected subjects by simulating the image rebinning process. A dynamic software generated phantom (dSGP) was created by moving a solid circle (to mimic the "tumor") with dMRI-determined motion trajectories. The gating window internal target area (ITAGw, 2D counterpart of ITVGW) was determined from both RedCAM and dSGP/dMRI. Its area (A), major axis (L1), minor axis (L2), and similarity (S) were calculated and compared. In the phantom study of 3 cm tumor, measurements of the ITAGW from dSGP (A =10.0 +/- 1.3 cm2, L1=3.8 +/- 0.4 cm, and L2=3.3 +/- 0.1 cm) are significantly (p <0.001) greater than those from RedCAM (A=8.5 +/- 0.7 cm(2), L1 =3.5 +/- 0.2 cm, and L2=3.1 +/- 0.1 cm). Similarly, the differences are significantly greater (p <0.001) for the 1 cm tumor (A=1.9 +/- 0.5 cm(2), L1 =1.9 +/- 0.4 cm, and L2=1.3 +/- 0.1 cm in dSGP; A=l1.3 +/- 0.1 cm(2), L1=1.5 +/- 0.2 cm, and L2 = 1.1 +/- 0.1 cm in RedCAM). In patient studies, measurements of the ITAGW from dMRI (A =15.5 +/- 8.2 cm(2), Ll=5.0 +/- 1.1 cm, and L2=3.8 +/- 1.2 cm) are also significantly greater (p <0.05) than those from RedCAM (A=13.2 +/- 8.5 cm(2), L1=4.3 +/- 1.4 cm, and L2=3.7 +/- 1.2 cm). Similarities were 0.9 +/- 0.1, 0.8 +/- 0.1, and 0.8 +/- 0.1 in the 3 cm tumor phantom, 1 cm tumor phantom, and patient studies, respectively. ITVGW can be underestimated by 4DCT due to breathing variations. An additional margin may be needed to account for this potential error in generating a PTVGW. Cautions need to be taken when generating ITVGW from 4DCT in respiratory gated radiation therapy, especially for small tumors (<3 cm) with a large motion range (>1 cm).

Contrôle de la respiration en radiothérapie: principaux aspects techniques et intérêts cliniques

Respiration-gated radiotherapy offers a significant potential for improvement in the irradiation of tumor sites affected by respiratory motion such as lung, breast and liver tumors. An increased conformality of irradiation fields leading to decreased complications rates of organs at risk (lung, heart…) is expected. Reduction of respiratory motion can be achieved by using either respiration synchronized gating techniques or breath hold techniques. This work describes the different techniques, gives an overview of the literature and results of the STIC 2003 project.

Dosimetric Analysis of Respiratory-Gated Radiotherapy for Hepatocellular Carcinoma

The purpose of this study was to define individualized internal target volume (ITV) for hepatocellular carcinoma (HCC) using 4D computed tomography (4DCT), and to determine the geometric and dosimetric benefits of respiratory gating. Gross tumor volumes (GTVs) were contoured on 10 respiratory phases of 4DCT images for 12 patients with HCC. Three treatment plans were prepared using different planning target volumes (PTVs): (1) PTV 3D, derived from a single helical clinical target volume (CTV) plus conventional margins; (2) PTV 10 phases, derived from ITV 10 phases, which encompassed all 10 CTVs plus an isotropic margin of 0.8 cm; (3) PTV gating, derived from ITV gating, which encompassed three CTVs within gating-window at end-expiration plus an isotropic margin of 0.8 cm. The PTV 3D was the largest volume for all patients. The ITV-based plans and gating plans spared more normal tissues than 3D plans, especially the liver. Without increasing normal tissue complication probability of the 3D plans, the ITV-based plans allowed for increasing the calculated dose from 50.8 Gy to 54.7 Gy on average, and the gating plans could further escalate the dose to 58.5 Gy. Compared with ITV-based plans, the dosimetric gains with gating plan strongly correlated with GTV mobility in the craniocaudal direction. The ITV-based plans can ensure target coverage with less irradiation of normal tissues compared with 3D plans. Respiratory-gated radiotherapy can further reduce the target volumes to spare more surrounding tissues and allow dose escalation, especally for patients with tumor mobility >1 cm.

The potential clinical benefit of respiratory gated radiotherapy (RGRT) in non-small cell lung cancer (NSCLC)

Background There is a great deal of excitement regarding respiratory gated radiotherapy (RGRT), however there remain potential errors and controversies surrounding its use. We aim to predict an improvement in the clinical outcome of RGRT in comparison with that of continuous (non-gated) irradiation by analysing toxicity parameters. Materials and methods The 4DCT scans of 15 patients, with node-positive lung cancer and >5 mm of tumour movement, were used for this retrospective analysis. End-inspiration and end-expiration plans were created and the toxicity parameters were compared to continuous (non-gated) 4DCT plans. Results Median reduction in V20 with inspiratory gating and expiratory gating, using a 10 mm set-up margin, was 2.0% (range 0.7% to 3.9%) and 0.6% (range −1.1% to 4.7%), respectively. The reduction in MLD was 2.1 Gy (range 0.6 to 3.9 Gy) and 1.6 Gy (range −1.0 to 3.9 Gy), respectively. Conclusions Although there is a widespread excitement regarding this technique, this study demonstrates that there is limited reduction in toxicity parameters with the use of RGRT in comparison with continuous (non-gated) 4DCT irradiation. Due to the additional potential errors involved in RGRT, we feel that currently, it should only be performed if comparative planning of RGRT plans and continuous (non-gated) 4DCT plans has been undertaken and a likely clinical benefit has been confirmed.

Evaluation of the need for simultaneous orthogonal gated setup imaging

Image‐guided patient setup for respiratory‐gated radiotherapy often relies on a pair of respiratory‐gated orthogonal radiographs, acquired one after the other. This study quantifies the error due to changes in the internal/external correlation which may affect asynchronous (non‐simultaneous) imaging. The dataset from eight patients includes internal and external coordinates acquired at 30Hz during multi‐fraction SBRT treatments using the Mitsubishi RTRT system coupled with an external surrogate gating device. We performed a computational simulation of the position of an implanted fiducial marker in an asynchronous orthogonal image set. A comparison is made to the reference position, the actual 3D fiducial location at the initial time point, as would be obtainable by simultaneous orthogonal setup imaging at that time point. The time interval between the two simulated radiographic acquisitions was set to a minimum of 30, 60 or 90 seconds, based on our clinical experience. The setup position is derived from a combination of both the initial (AP) and the final (LR) simulated 2D images in the following way: LRsetup=LRinitial,SIsetup=SIinitial+(SIfinal−SIinitial)/2,APsetup=APfinal. The 3D error is then the magnitude of the vector from the initial (reference) position to the setup position. The calculation was done for every exhale phase in the data for which there was another one at least 30, 60 or 90 seconds later, at an amplitude within 0.5 mm from the first. A correlation between the time interval and the 3D error was also sought. The mean 3D error is found to be roughly equivalent for time intervals (tinterval) of 30, 60 and 90 seconds between the orthogonal simulated images (0.8 mm, 0.8 mm, 0.6 mm, respectively). The 3D error is less than 1, 2 and 3 mm for 77%, 89% and 98% of the data points, respectively. The actual time between simulated images turned out to be very close to tinterval, with 90% of the second simulated image acquisitions being completed within 38, 68 and 95 seconds of the first simulated image for tinterval of 30, 60 and 90 seconds, respectively. No correlation was found between the length of the time interval and the 3D error. When acquiring respiratory‐gated radiographs for patient setup, only small errors should be expected if those images are not taken simultaneously.PACS number: 87.55.ne

The limited clinical benefit of respiration gated radiotherapy (RGRT) in non-small cell lung cancer (NSCLC)

The limited clinical benefit of respiration gated radiotherapy (RGRT) in non-small cell lung cancer (NSCLC)

Technological advances in radiotherapy for esophageal cancer

Radiotherapy with concurrent chemotherapy and surgery represent the main treatment modalities in esophageal cancer. The goal of modern radiotherapy approaches, based on recent technological advances, is to minimize post-treatment complications by improving the gross tumor volume definition (positron emission tomography-based planning), reducing interfraction motion (image-guided radiotherapy) and intrafraction motion (respiratory-gated radiotherapy), and by better dose delivery to the precisely defined planning target volume (intensity-modulated radiotherapy and proton therapy). Reduction of radiotherapy-related toxicity is fundamental to the improvement of clinical results in esophageal cancer, although the dose escalation concept is controversial.

Predictive Factors for Lung Dose Reduction by Respiratory Gating at Radiotherapy for Lung Cancer

This study aimed to identify factors predictive of the benefit of respiratory-gated radiotherapy. Three plans were created for 25 patients with non-small cell lung cancer, simulating the following 3 treatment scenarios. Protocol 1 was non-gated and the lung dose was calculated using 4-s slow CT (PnA), protocol 2 was also non-gated and the lung dose was calculated by CT at the end-expiration phase (PnE), and protocol 3 applied phase-based gating around end-expiration (PgE). We correlated possible predictive factors with the estimated lung dose reduction achieved by respiratory gating. The 3D clinical target volume (CTV) motion, craniocaudal CTV motion, and the craniocaudal CTV position were correlated with the reduction in V20 and the mean lung dose (p < 0.01). CTV was not significantly correlated with the estimated lung dose reduction. The area under the ROC curve (AUC) for 3D- and craniocaudal CTV motion, and craniocaudal CTV position was 1.000, 0.997, and 0.943, respectively, when the threshold for selecting patients was set at a 1% reduction of V20 and at a 0.5 Gy reduction in the mean lung dose. The results of the present study suggest that 3D CTV motion, craniocaudal CTV motion, and the craniocaudal CTV position are useful for predicting the benefit of respiratory-gated radiotherapy in lung cancer patients.

A feasibility study of markerless fluoroscopic gating for lung cancer radiotherapy using 4DCT templates

A major difficulty in conformal lung cancer radiotherapy is respiratory organ motion, which may cause clinically significant targeting errors. Respiratory-gated radiotherapy allows for more precise delivery of prescribed radiation dose to the tumor, while minimizing normal tissue complications. Gating based on external surrogates is limited by its lack of accuracy, while gating based on implanted fiducial markers is limited primarily by the risk of pneumothorax due to marker implantation. Techniques for fluoroscopic gating without implanted fiducial markers (markerless gating) have been developed. These techniques usually require a training fluoroscopic image dataset with marked tumor positions in the images, which limits their clinical implementation. To remove this requirement, this study presents a markerless fluoroscopic gating algorithm based on 4DCT templates. To generate gating signals, we explored the application of three similarity measures or scores between fluoroscopic images and the reference 4DCT template: un-normalized cross-correlation (CC), normalized cross-correlation (NCC) and normalized mutual information (NMI), as well as average intensity (AI) of the region of interest (ROI) in the fluoroscopic images. Performance was evaluated using fluoroscopic and 4DCT data from three lung cancer patients. On average, gating based on CC achieves the highest treatment accuracy given the same efficiency, with a high target coverage (average between 91.9% and 98.6%) for a wide range of nominal duty cycles (20–50%). AI works well for two patients out of three, but failed for the third patient due to interference from the heart. Gating based on NCC and NMI usually failed below 50% nominal duty cycle. Based on this preliminary study with three patients, we found that the proposed CC-based gating algorithm can generate accurate and robust gating signals when using 4DCT reference template. However, this observation is based on results obtained from a very limited dataset, and further investigation on a larger patient population has to be done before its clinical implementation.

Residual Motion and Duty Time in Respiratory Gating Radiotherapy Using Individualized or Population-Based Windows

The efficiency and precision of respiratory gated radiation therapy for tumors is affected by variations in respiration-induced tumor motion. We evaluated the use of individualized and population-based parameters for such treatment. External respiratory signal records and images of respiration-induced tumor motion were obtained from 42 patients undergoing respiratory gated radiation therapy for liver tumors. Gating window widths were calculated for each patient, with 2, 4, and 10 mm of residual motion, and the mean was defined as the population-based window width. Residual motions based on population-based and predefined window widths were compared. Duty times based on whole treatment sessions, at various window levels, were calculated. The window level giving the longest duty time was defined as the individualized most efficient level (MEL). MELs were also calculated based on the first 10 breathing cycles. The duty times for population-based MELs (defined as mean MELs) and individualized MELs were compared. Tracks of respiration-induced tumor motion ranged from 3 to 50 mm. Half of the patients had larger actual residual motions than the assigned residual motions. Duty times were greater when based on individualized, rather than population-based, window widths. The MELs established during whole treatment sessions for 2 mm and 4 mm of residual motion gave significantly increased duty times, whereas those calculated using the first 10 breathing cycles showed only marginal increases. Using individualized window widths and levels provided more precise and efficient respiratory gated radiation therapy. However, methods for predicting individualized window levels before treatment remain to be explored.

Synchronous monitoring of external/internal respiratory motion: validity of respiration-gated radiotherapy for liver tumors

Four-dimensional (4D) radiotherapy, in particular respiration gating for the treatment of lung tumors, is gaining popularity. Its utility for other sites, however, has not been investigated fully. The purpose of this study was to see whether 4D therapy is feasible for liver tumors. Six patients (five with hepatomas and one with metastatic liver tumor) had a fiducial, gold marker 1.5 mm in diameter implanted in the vicinity of their liver tumors. The inner and external (i.e., upper abdominal wall) respiratory movements were simultaneously recorded using a real-time tumor-tracking radiotherapy system and respiration monitor equipment applied to the mid to upper abdomen. The fluctuations from the baseline position of liver tumors were small; the mean absolute value was 3.92 +/- 1.94 mm. The mean right-left, anteroposterior, and craniocaudal total movements were 4.19 +/- 2.46, 7.23 +/- 2.96, and 15.98 +/- 6.02 mm, respectively. The phase shift was negligible. Liver tumors may be suitable for respiration-gated radiotherapy, and they may become curable with 4D radiotherapy.