Varian RPM System Research Articles

Validating the clinical use of Breathe Well, a novel breathe monitoring device.

Respiratory motion management has become increasingly important in the accurate delivery of radiotherapy. Recently, a novel device, Breathe Well, has been developed, which provides motion management by tracking the movement of external surrogates. This paper has comprehensively assessed the measurement accuracy of Breathe Well in various clinical conditions. The results suggest that the Breathe Well device has good reproducibility, although it demonstrates larger measurement errors in certain setup positions. However, this measurement error becomes trivial if it is setup consistently over the entire course of treatment. For other setup positions, the Breathe Well device can reach a ± 1.0mm spatial accuracy when the motion amplitude is less than or equal to 20mm, similar to that of the Varian RPM system. The phase measurement from Breathe Well agrees well with that of the RPM and the QUASAR phantom, indicating that the device has potentials for phase-related clinical applications such as gating.

Reducing 4D CT imaging artifacts at the source: first experimental results from the respiratory adaptive computed tomography (REACT) system

Breathing variations during 4D CT imaging often manifest as geometric irregularities known as respiratory-induced image artifacts and ultimately effect radiotherapy treatment efficacy. To reduce such image artifacts we developed Respiratory Adaptive Computed Tomography (REACT) to trigger CT acquisition during periods of regular breathing. For the first time, we integrate REACT with clinical hardware and hypothesize that REACT will reduce respiratory-induced image artifacts ≥ 4 mm compared to conventional 4D CT.4D image sets were acquired using REACT and conventional 4D CT on a Siemens Somatom scanner. Scans were taken for 13 respiratory traces (12 patients) that were reproduced on a lung-motion phantom. Motion was observed by the Varian RPM system and sent to the REACT software where breathing irregularity was evaluated in real-time and used to trigger the imaging beam. REACT and conventional 4D CT images were compared to a ground truth static-phantom image and compared for absolute geometric differences within the region-of-interest. Breathing irregularity during imaging was retrospectively assessed using the root-mean-square error of the RPM measured respiratory signal during beam on (RMSE_Beam_on) for each phase of the respiratory cycle.REACT significantly reduced the average frequency of respiratory-induced image artifacts ≥ 4 mm by 70% for the tumor (p = 0.003) and 76% for the lung (p = 0.0002) compared to conventional 4D CT. Volume reductions of 10% to 6% of the tumor and 2% to 1% of the lung compared to conventional 4D CT were seen. Breathing irregularity during imaging (RMSE_Beam_on) was significantly reduced by 27% (p = 0.013) using the REACT method.For the first time, REACT was successfully integrated with clinical hardware. Our findings support the hypothesis that REACT significantly reduced respiratory-induced image artifacts compared to conventional 4D CT. These experimental results provide compelling evidence for further REACT investigation, potentially providing clearer images for clinical use.

Evaluation of Daily Tumor Motion by Measuring Fiducial Length on CBCT Images in Pancreatic Stereotactic Body Radiation Therapy

We investigated the feasibility of measuring daily fiducial length on cone-beam computed tomography (CBCT) images to assess the variation in daily tumor motion for pancreatic SBRT. Motion data for fifty pancreatic SBRT patients with fiducials were analyzed retrospectively to determine the tumor motion statistics. We also performed a phantom study which involved motion analysis of three gold fiducials placed around a solid target inside the Quasar Phantom as a function of variable tumor motion and breathing period. The end-exhalation CT-50 images were compared with the CBCT images acquired prior to treatment delivery on a TrueBeam STx linear accelerator. Sinusoidal tumor motion and patients’ breathing files acquired from a Varian-RPM system were used to simulate patients’ breathing patterns. The fiducial length was measured to determine its correlation with tumor motion. Patient tumor motions along the superior-inferior (SI), anterior-posterior (AP), and left-right (LR) directions were found to be 0.7 ± 0.4 cm, 0.2 ± 0.3 cm, and 0.1 ± 0.2 cm, respectively. Average breathing period was 4.3 ± 0.8 seconds. For sinusoidal and patients’ breathing patterns, a significant correlation was observed between the fiducial length and tumor motions with R2 of 0.99. However, fiducial length was found to be independent of the variation in breathing periods. This work suggests that measuring the fiducial length on daily CBCT images could provide quantitative daily tumor motion for fiducial-based pancreatic SBRT. A timely decision to modify the motion management strategy could be made prior to daily treatment delivery.

Effects of irregular respiratory motion on the positioning accuracy of moving target with free breathing cone-beam computerized tomography.

For positioning a moving target, a maximum intensity projection (MIP) or average intensity projection (AIP) image derived from 4DCT is often used as the reference image which is matched to free breathing cone-beam CT (FBCBCT) before treatment. This method can be highly accurate if the respiratory motion of the patient is stable. However, a patient’s breathing pattern is often irregular. The purpose of this study is to investigate the effects of irregular respiration on positioning accuracy for a moving target aligned with FBCBCT. Nine patients’ respiratory motion curves were selected to drive a Quasar motion phantom with one embedded cubic and two spherical targets. A 4DCT of the phantom was acquired on a CT scanner (Philips Brilliance 16) equipped with a Varian RPM system. The phase binned 4DCT images and the corresponding MIP and AIP images were transferred into Eclipse for analysis. FBCBCTs of the phantom driven by the same respiratory curves were also acquired on a Varian TrueBeam and fused such that both CBCT and MIP/AIP images share the same target zero positions. The sphere and cube volumes and centroid differences (alignment error) determined by MIP, AIP and FBCBCT images were calculated, respectively. Compared to the volume determined by MIP, the volumes of the cube, large sphere, and small sphere in AIP and FBCBCT images were smaller. The alignment errors for the cube, large sphere and small sphere with center to center matches between MIP and FBCBCT were 2.5 ± 1.8mm, 2.4±2.1 mm, and 3.8±2.8 mm, and the alignment errors between AIP and FBCBCT were 0.5±1.1mm, 0.3±0.8mm, and 1.8±2.0 mm, respectively. AIP images appear to be superior reference images to MIP images. However, irregular respiratory pattern could compromise the positioning accuracy, especially for smaller targets.

MO-FG-BRA-03: A Novel Method for Characterizing Gating Response Time in Radiation Therapy

Purpose: Low temporal latency between a gating ON/OFF signal and the LINAC beam ON/OFF during respiratory gating is critical for patient safety. Current film based methods to assess gating response have poor temporal resolution and are highly qualitative. We describe a novel method to precisely measure gating lag times at high temporal resolutions and use it to characterize the temporal response of several gating systems. Methods: A respiratory gating simulator with an oscillating platform was modified to include a linear potentiometer for position measurement. A photon diode was placed at linear accelerator isocenter for beam output measurement. The output signals of the potentiometer and diode were recorded simultaneously at 2500 Hz (0.4 millisecond (ms) sampling interval) with an analogue-to-digital converter (ADC). The techniques was used on three commercial respiratory gating systems. The ON and OFF of the beam signal were located and compared to the expected gating window for both phase and position based gating and the temporal lag times extracted using a polynomial fit method. Results: A Varian RPM system with a monoscopic IR camera was measured to have mean beam ON and OFF lag times of 98.2 ms and 89.6 ms, respectively. A Varian RPM system with a stereoscopic IR camera was measured to have mean beam ON and OFF lag times of 86.0 ms and 44.0 ms, respectively. A Calypso magnetic fiducial tracking system was measured to have mean beam ON and OFF lag times of 209.0 ms and 60.0 ms, respectively. Conclusions: A novel method allowed for quantitative determination of gating timing accuracy for several clinically used gating systems. All gating systems met the 100 ms TG-142 criteria for mean beam OFF times. For beam ON response, the Calypso system exceeded the recommended response time.

SU-G-JeP1-14: Respiratory Motion Tracking Using Kinect V2

Purpose: Investigate capability and accuracy of Kinect v2 camera for tracking respiratory motion to use as a tool during 4DCT or in combination with motion management during radiotherapy treatments. Methods: Utilizing the depth sensor on the Kinect as well as code written in C#, the respiratory motion of a patient was tracked by recording the depth (distance) values obtained at several points on the patient. Respiratory traces were also obtained using Varian's RPM system, which traces the movement of a propriety marker placed on the patient's abdomen, as well as an Anzai belt, which utilizes a pressure sensor to track respiratory motion. With the Kinect mounted 60 cm above the patient and pointing straight down, 11 breathing cycles were recorded with each system simultaneously. Relative displacement values during this time period were saved to file. While RPM and the Kinect give displacement values in distance units, the Anzai system has arbitrary units. As such, displacement for all three are displayed relative to the maximum value for the time interval from that system. Additional analysis was performed between RPM and Kinect for absolute displacement values. Results: Analysis of the data from all three systems indicates the relative motion obtained from the Kinect is both accurate and in sync with the data from RPM and Anzai. The absolute displacement data from RPM and Kinect show similar displacement values throughout the acquisition except for the depth obtained from the Kinect during maximum exhalation (largest distance from Kinect). Conclusion: By simply utilizing the depth data of specific points on a patient obtained from the Kinect, respiratory motion can be tracked and visualized with accuracy comparable to that of the Varian RPM and Anzai belt.

SU‐F‐T‐644: Reproducibility of Target Position Using Moderate Voluntary Breath‐ Hold During Liver Stereotactic Ablative Radiotherapy

Purpose:To evaluate the reproducibility of target position using moderate voluntary breath‐hold during liver stereotactic ablative radiotherapy (SABR).Methods:Two patients who underwent liver SABR on a Varian TrueBeam STx linac were used for this study. Fiducial markers were placed in and around the target in the liver as surrogates for the target position and motion. GTVs were contoured by assessing tumor extent on contrast enhanced CT. The PTV was created from the GTV by adding 2 mm margins to account for the residual motion during breath‐holds. A portable biofeedback system was used to facilitate the breath‐hold to a reproducible position. The Varian RPM system was used for gating the linac. Proceeding each treatment, orthogonal kV pairs were taken, and alignment to nearby bony anatomy was performed. Then the breath‐hold CBCT was acquired to align the fiducial markers. On‐line fluoroscopy was used to fine‐tune the breath‐hold gating thresholds to correlate with the positions of the fiducial markers. The inter‐fraction reproducibility of the target was evaluated by the offsets of the daily breath‐hold CBCTs from the paired kV matches as a direct measure of the target position relative to the bony anatomy. The intra‐fraction reproducibility of the target position was assessed by the gated window of the RPM marker block for each fraction.Results:The absolute mean offsets between the CBCT and paired kV matches in the vertical, longitudinal, and lateral directions were 0.06 cm, 0.10 cm, and 0.06 cm for patient 1, and 0.37 cm, 0.62 cm, and 0.09 cm for patient 2. The gated window of the RPM marker block for the breath‐hold for each fraction was within 0.63 ± 0.16 cm and 0.59 ± 0.12 cm for patients 1 and 2, respectively.Conclusion:Moderate voluntary breath‐hold showed good inter‐ and intra‐fraction reproducibility of target position during liver SABR.

TH-AB-202-07: Radar Tracking of Respiratory Motion in Real Time

Purpose: To propose a method of real time tracking of respiratory motion in patients undergoing radiation therapy. Radar technology can be employed to detection the movement of diaphragm and thoracic anatomy. Methods: A radar transceiver was specially designed. During experiment, the radar device was securely attached to a fixed frame. Respiratory motion was simulated with: 1) Varian RPM phantom, 2) Standard Imaging Respiratory Gating Platform. Signals recorded with radar equipment were compared with those measured with Varian RPM system as a reference. Results: Motion generated by Varian RPM phantom was recorded by the radar device, and compared to the signals recorded by RPM camera. The results showed exact agreement between the two monitoring equipments. Motion was also generated by Standard Imaging Respiratory Motion Platform. The results showed the radar device was capable of measuring motion of various amplitudes and periods. Conclusion: The proposed radar device is able to measure movements such as respiratory motion. Compared to state-of-the-art respiratory detection instrument, the radar device is shown to be equally precise and effective for monitoring respiration in radiation oncology patients.

SU‐F‐T‐253: Volumetric Comparison Between 4D CT Amplitude and Phase Binning Mode

Purpose:Motion artifact in 4DCT images can affect radiation treatment quality. To identify the most robust and accurate binning method, we compare the volume difference between targets delineated on amplitude and phase binned 4DCT scans.Methods:Varian RPM system and CT scanner were used to acquire 4DCTs of a Quasar phantom with embedded cubic and spherical objects having superior‐inferior motion. Eight patients’ respiration waveforms were used to drive the phantom. The 4DCT scan was reconstructed into 10 phase and 10 amplitude bins (2 mm slices). A scan of the static phantom was also acquired. For each waveform, sphere and cube volumes were generated automatically on each phase using HU thresholding. Phase (amplitude) ITVs were the union of object volumes over all phase (amplitude) binned images. The sphere and cube volumes measured in the static phantom scan were Vsphere=4.19cc and Vcube=27.0cc. Volume difference (VD) and dice similarity coefficient (DSC) of the ITVs, and mean volume error (MVE) defined as the average target volume percentage difference between each phase image and the static image, were used to evaluate the performance of amplitude and phase binning.Results:Averaged over the eight breathing traces, the VD and DSC of the internal target volume (ITV) between amplitude and phase binning were 3.4%±3.2% (mean ± std) and 95.9%±2.1% for sphere; 2.1%±3.3% and 98.0% ±1.5% for cube, respectively.For all waveforms, the average sphere MVE of amplitude and phase binning was 6.5% ± 5.0% and 8.2%±6.3%, respectively; and the average cube MVE of amplitude and phase binning was 5.7%±3.5%and 12.9%±8.9%, respectively.Conclusion:ITV volume and spatial overlap as assessed by VD and DSC are similar between amplitude and phase binning. Compared to phase binning, amplitude binning results in lower MVE suggesting it is less susceptible to motion artifact.

SU‐G‐JeP4‐05: Effects of Irregular Respiratory Motion On the Positioning Accuracy of Moving Target with Free Breathing Cone‐Beam Computerized Tomography

Purpose:Average or maximum intensity projection (AIP or MIP) images derived from 4DCT images are often used as a reference image for target alignment when free breathing Cone‐beam CT (FBCBCT) is used for positioning a moving target at treatment. This method can be highly accurate if the patient has stable respiratory motion. However, a patient's breathing pattern often varies irregularly. The purpose of this study is to investigate the effect of irregular respiration on the positioning accuracy of a moving target with FBCBCT.Methods:Eight patients’ respiratory motion curves were selected to drive a Quasar phantom with embedded cubic and spherical targets. A 4DCT of the moving phantom was acquired on a CT scanner (Philips Brilliance 16) equipped with a Varian RPM system. The phase binned 4DCT images and the corresponding MIP and AIP images were transferred into Eclipse for analysis. CBCTs of the phantom driven by the same breathing curves were acquired on a Varian TrueBeam and fused such that the zero positions of moving targets are the same on both CBCT and AIP images. The sphere and cube volumes and centrioid differences (alignment error) determined by MIP, AIP and FBCBCT images were compared.Results:Compared to the volume determined by FBCBCT, the volumes of cube and sphere in MIP images were 22.4%±8.8% and 34.2%±6.2% larger while the volumes in AIP images were 7.1%±6.2% and 2.7%±15.3% larger, respectively. The alignment errors for the cube and sphere with center‐center matches between MIP and FBCBCT were 3.5±3.1mm and 3.2±2.3mm, and the alignment errors between AIP and FBCBCT were 2.1±2.6mm and 2.1±1.7mm, respectively.Conclusion:AIP images appear to be superior reference images than MIP images. However, irregular respiratory motions could compromise the positioning accuracy of a moving target if the target center‐center match is used to align FBCBCT and AIP images.

SU‐F‐T‐636: Comprehensive Approach to Motion Assessment for Liver and Pancreas SBRT Patients

Purpose:Our past practice for liver and pancreas SBRT consisted of free breathing (FB) with gated treatment delivery using a 30‐70% phase window. We have recently adopted an assessment method leading to individualized motion management to minimize target motion. We present our results from 47 patients treated with this new approach.Methods:We perform an initial patient coaching and assessment session in our conventional simulator suite to observe the motion of the implanted fiducials with FB anterior and lateral 20‐second cine acquisitions. The physician decides whether to attempt inhale or exhale breath‐hold (BH). The patient is coached while observing with cine to ascertain their ability to achieve the desired BH mode for long periods as needed for treatment delivery. If the patient cannot comply, a FB approach is adopted using gating or simple ITV method (for patients without fiducials). After achieving a patient‐specific motion management mode, we perform CT‐simulation using the Varian RPM system to reproduce the chosen mode and record a reference session for treatment delivery. For pre‐treatment imaging, the fiducials are observed under fluoro while coaching the patient.Results:Of 47 SBRT cases analyzed, 32 were liver and 15 were pancreas. The chosen techniques were: 32 exhale BH (12 with abdominal compression), 7 FB gated, 4 inhale BH, and 4 FB ITV. Maximum fiducial motion amplitude was 5 mm for the FB gated patients, and less than 5 mm for all BH patients with most able to achieve a maximum amplitude of 3 mm.Conclusion:This study showed that an individualized motion management approach can reduce the target volume and, therefore, the volume of irradiated healthy tissue from liver or pancreas SBRT. Effective coaching is essential in achieving consistent BH with 3 mm amplitude. The fluoro/cine session is helpful in establishing the right coaching approach for each patient.

SU‐F‐T‐254: Dose Volume Histogram (DVH) Analysis of Breath Hold Vs Free Breathing Techniques for Esophageal Tumors

Purpose:Lung and heart doses and associated toxicity are of concern in radiotherapy for esophageal cancer. This study evaluates the dosimetry of deep‐inspiration‐breath‐hold (DIBH) technique as compared to freebreathing(FB) using 3D‐conformal treatment(3D‐CRT) of esophageal cancer.Methods:Eight patients were planned with FB and DIBH CT scans. DIBH scans were acquired using Varian RPM system. FB and DIBH CTs were contoured per RTOG‐1010 to create the planning target volume(PTV) as well as organs at risk volumes(OAR). Two sets of gross target volumes(GTV) with 5cm length were contoured for each patient: proximal at the level of the carina and distal at the level of gastroesophageal junction and were enlarged with appropriate margin to generate Clinical Target Volume and PTV. 3D‐CRT plans were created on Eclipse planning system for 45Gy to cover 95% of PTV in 25 fractions for both proximal and distal tumors on FB and DIBH scans. For distal tumors celiac nodes were covered electively. DVH parameters for lung and heart OARs were generated and analyzed.Results:All DIBH DVH parameters were normalized to FB plan values. Average of heart‐mean and heart‐V40 was 0.70 and 0.66 for proximal lesions. For distal lesions ratios were 1.21 and 2.22 respectively. For DIBH total lung volume increased by 2.43 times versus FB scan. Average of lung‐mean, V30, V20, V10, V5 are 0.82, 0.92, 0.76, 0.77 and 0.79 for proximal lesions and 1.17,0.66,0.87,0.93 and 1.03 for distal lesions. Heart doses were lower for breath‐hold proximal lesions but higher for distal lesions as compared to free‐breathing plans. Lung doses were lower for both proximal and distal breath‐hold lesions except mean lung dose and V5 for distal lesions.Conclusion:This study showed improvement of OAR doses for esophageal lesions at mid‐thoracic level utilizing DIBH vs FB technique but did not show consistent OAR sparing with DIBH for distal lesions.

Accuracy Verification of Respiratory-gated Radiotherapy that Combines the Respiration-Monitoring Device and Respiratory-gated System.

The purpose of this study is to evaluate the mechanical accuracy of a respiratory-gated radiation system that combines the Linear Indicator-equipped Abches respiration-monitoring device and the Varian Real-time Position Management system (LI-RPM system). This combined configuration, implemented for the first time in Japan, was compared with the stand-alone Varian RPM system (RPM system). The delay times, dose profiles, and output waveforms of the LI-RPM and RPM systems were evaluated using a self-produced dynamic phantom. The delay times for the LI-RPM and RPM systems were both 0.1 s for 4 s and 8 s test periods. The corresponding output waveform correlation factors (R2) for the 4 s and 8 s test periods were 0.9981 and 0.9975, respectively. No difference was observed in the dose profiles of the two systems. Thus, the present results indicate that the proposed LI-RPM combined respiratory-gated radiation system has similar properties to the RPM system. However, it offers several advantages in terms of its versatility, including its alignment assistance capabilities for non-coplanar treatments.

Respiratory surface motion measurement by Microsoft Kinect

Abstract In radiotherapy of abdominal and thoracic tumors, respiratory motion is a problem for an accurate treatment. Most current motion compensation techniques rely on externally acquired breathing signals of the patient. The systems in clinical use usually work with 1D surface motion signals to describe internal structure respiratory motion patterns. As a 1D signal is not able to describe complex motion patterns and breathing variations, in this work the Microsoft Kinect, which can record multidimensional respiratory surface motion signals, is proposed to be used instead. For the Kinect, a clinically acceptable measurement setup is designed and Kinect measurements are compared to the Varian RPM system (clinical standard). The results show that the signals are well aligned. An additional comparison of Kinect signals from different regions of interest on the chest further reveals variations between them. This illustrates that the use of a system that provides multidimensional signals is worthwhile; the knowledge about breathing variations could be applied for optimization of current clinical workflows.

SU‐E‐T‐651: Quantification of Dosimetric Accuracy of Respiratory Gated Stereotactic Body Radiation Therapy

Purpose:To quantify the dosimetric accuracy of respiratory gated stereotactic body radiation therapy delivery using dynamic thorax phantom.Methods:Three patients with mobile target (2 lung, 1liver) were chosen. Retrospective 4DCT image sets were acquired for using Varian RPM system. An in‐house MATLAB program was designed for MIP, MinIP and AvgIP generation. ITV was contoured on MIP image set for lung patients and on MinIP for liver patient. Dynamic IMRT plans were generated on selected phase bin image set in Eclipse (v10.0) planning system. CIRS dynamic thorax phantom was used to perform the dosimetric quality assurance. Patient breathing pattern file from RPM system was converted to phantom compatible file by an in‐house MATLAB program. This respiratory pattern fed to the CIRS dynamic thorax phantom. 4DCT image set was acquired for this phantom using patient breathing pattern. Verification plans were generated using patient gating window and delivered on the phantom. Measurements were carried out using with ion chamber and EBT2 film. Exposed films were analyzed and evaluated in FilmQA software.Results:The stability of gated output in comparison with un‐gated output was within 0.5%. The Ion chamber measured and TPS calculated dose compared for all the patients. The difference observed was 0.45%, −0.52% and −0.54 for Patient 1, Patient2 and Patient 3 respectively.Gamma value evaluated from EBT film shows pass rates from 92.41% to 99.93% for 3% dose difference and 3mm distance to agreement criteria.Conclusion:Dosimetric accuracy of respiratory gated SBRT delivery for lung and liver was dosimetrically acceptable. The Ion chamber measured dose was within 0.203±0.5659% of the expected dose. Gamma pass rates were within 96.63±3.84% of the expected dose.

SU‐E‐J‐153: Reconstructing 4D Cone Beam CT Images for Clinical QA of Lung SABR Treatments

Purpose:To verify that the planned Primary Target Volume (PTV) and Internal Gross Tumor Volume (IGTV) fully enclose a moving lung tumor volume as visualized on a pre‐SABR treatment verification 4D Cone Beam CT.Methods:Daily 3DCBCT image sets were acquired immediately prior to treatment for 10 SABR lung patients using the on‐board imaging system integrated into a Varian TrueBeam (v1.6: no 4DCBCT module available). Respiratory information was acquired during the scan using the Varian RPM system. The CBCT projections were sorted into 8 bins offline, both by breathing phase and amplitude, using in‐house software. An iterative algorithm based on total variation minimization, implemented in the open source reconstruction toolkit (RTK), was used to reconstruct the binned projections into 4DCBCT images. The relative tumor motion was quantified by tracking the centroid of the tumor volume from each 4DCBCT image. Following CT‐CBCT registration, the planning CT volumes were compared to the location of the CBCT tumor volume as it moves along its breathing trajectory. An overlap metric quantified the ability of the planned PTV and IGTV to contain the tumor volume at treatment.Results:The 4DCBCT reconstructed images visibly show the tumor motion. The mean overlap between the planned PTV (IGTV) and the 4DCBCT tumor volumes was 100% (94%), with an uncertainty of 5% from the 4DCBCT tumor volume contours. Examination of the tumor motion and overlap metric verify that the IGTV drawn at the planning stage is a good representation of the tumor location at treatment.Conclusion:It is difficult to compare GTV volumes from a 4DCBCT and a planning CT due to image quality differences. However, it was possible to conclude the GTV remained within the PTV 100% of the time thus giving the treatment staff confidence that SABR lung treatements are being delivered accurately.

Abstract P2-14-08: Immediate breast reconstruction with anatomical implants following mastectomy: The Radiation perspective

Abstract Purpose: Immediate implant-based breast reconstruction followed by postmastectomy radiation therapy (PMRT) is controversial because of the risk of compromised treatment plans, particularly left-sided plans including internal mammary nodes (IMNs) as target. Using direct-to-implant reconstruction with anatomical implants may improve plans due to their unique shape over the chest wall. This single-institution study evaluated the effects of immediate breast reconstruction with anatomical implants on the quality of PMRT delivered by 3-dimensional conformal radiation therapy (3D-CRT). Methods and Materials: Patients undergoing immediate direct-to-implant reconstruction with anatomic implant, performed by a single surgeon, were treated between 2008 and 2013. For each patient, 2 plans were created and calculated, including or excluding IMNs. No electron fields were used. The primary endpoint was the dose distribution among reconstructed breast (RB), heart, lungs and IMNs and between right and left breasts. Six patients were treated with the Varian RPM system for left sided BC due to anterior heart position. Results: Of 29 consecutive patients, 11 received right-sided and 18 received left-sided PMRT. For plans excluding IMNs, mean Dmean was 49.09 Gy (98.2% of the prescribed dose) for right and 48.51 Gy (97.0%) for left RBs. For plans including IMNs, mean Dmean was 49.15 Gy (98.3%) for right and 48.46 Gy (96.9%) for left RBs. Mean RB D95 ranged from 42.05 Gy (left side with IMNs) to 45.15 Gy (right side with IMNs). Mean IMN Dmean was almost identical for left- and right-sided treatment (47.89 Gy and 47.27 Gy, respectively; P=.340). Heart doses were very low, with mean Dmean values of 1.25 Gy (range, 0.83-1.46) and 1.56 Gy (range, 1.23-2.10) for left-sided plans excluding and including IMNs, respectively (P<.001). Mean lung V20 values ranged from 13.80% for left-sided treatment excluding IMNs to 19.47% for right-sided treatment including IMNs. Conclusion: PMRT can be delivered effectively and safely by 3D-CRT after direct-to-implant breast reconstruction with anatomical implants. The reconstructed breast and the IM chain coverage were excellent and the heart dose was very low, (probably due to the use of the RPM system). Lungs V20 was comparable with other publication. Our study support the hypothesis that immediate breast reconstruction per se is not an impediment to the delivery of high-quality PMRT by modern 3D-CRT technology. Based on our findings, reconstructive surgeons should consider the use of anatomical implants for immediate breast reconstruction in patients requiring subsequent PMRT. Citation Format: Merav Akiva Ben-David, Hila Granot, Ilana Gelernter, Michael Scheflan. Immediate breast reconstruction with anatomical implants following mastectomy: The Radiation perspective [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-14-08.

SU-E-J-265: Practical Issues and Solutions in Reconstructing and Using 4DCT for Radiotherapy Planning of Lung Cancer

Purpose: To report practical issues and solutions in reconstructing and using 4DCT to account for respiratory motion in radiotherapy planning. Methods: Quiet breathing 4DCT was used to account for respiratory motion for patients with lung or upper abdomen tumor. A planning CT and a 4DCT were acquired consecutively with a Philips Brilliance CT scanner and Varian RPM System. The projections were reconstructed into 10 phases. In Pinnacle RTP system, we contour a GTV in each phase and unite all 10 GTVs as ITV. The ITV is then mapped to the planning CT. We describe practical issues, their causes, our solutions and reasoning during this process. Results: In 6 months, 9 issues were reported for 8 patients with lung cancer. For two patients, part of the GTV (∼50% and 10%) in planning CT fell outside the ITV in 4DCT. There was a 7 mm variation in first patient back position because less restricted immobilization had to be used. The second discrepancy was due to moderate variation in breathing amplitude. We extended the ITV to include the GTV since both variations may likely happen during treatment. A LUL tumor showed no motion due to a 10-s long no-breathing period. An RLL tumor appeared double due to an abnormally deeper breath at the tumor region. We repeated 4DCT reiterating the importance of quiet, regular breathing. One patient breathed too light to generate RPM signal. Two issues (no motion in lung, incomplete images in 90% phase) were due to incorrect tag positions. Two unexplainable errors disappeared when repeating reconstruction. In summary, 5 issues were patient-related and 4 were technique issues. Conclusion: Improving breathing regularity avoided large artifacts in 4DCT. One needs to closely monitor patient breathing. For uncontrollable variations, larger PTVs are necessary which requires appropriate communication between physics and the treating physician.

SU‐E‐J‐75: Importance of 4DCT for Target Volume Definition in Stereotactic Lung Radiotherapy

Purpose:We aimed to investigate the importance of 4DCT for lung tumors treated with SBRT and whether maximum intensity projection (MIP) and free breathing (FB) images can compansate for tumor movement.Methods:Six patients with primary lung cancer and 2 patients with lung metastasis with a median age of 69.5 (42–86) were included. Patients were positioned supine on a vacuum bag. In addition to FB planning CT images, 4DCT images were obtained at 3 mm intervals using Varian RPM system with (Siemens Somatom Sensetion 64). MIP series were reconstructed using 4DCT images. PTV‐FB and PTV‐MIP (GTV+5mm) volumes were contoured using FB and MIP series, respectively. GTVs were defined on each of eight different breathing phase images and were merged to create the ITV. PTV‐4D was generated with a 5 mm margin to ITV. PTV‐MIP and PTV‐4D contours were copied to FB CT series and treatment plans for PTV‐MIP and PTV‐FB were generated using RapidArc (2 partial arc) technique in Eclipse (version 11, AAA algorithm). The prescription dose was 5600cGy in 7 fractions. ITV volumes receiving prescription dose (%) and V95 for ITV were calculated for each treatment plan.Results:The mean PTV‐4B, PTV‐MIP and PTV‐FB volumes were 23.2 cc, 15.4cc ve 11cc respectively. Median volume of ITV receiving the prescription dose was 34.6% (16.4–70 %) and median V95 dose for ITV was 1699cGy (232cGy‐5117cGy) in the plan optimized for PTV‐FB as the reference. When the plan was optimized for PTV‐MIP, median ITV volume receiving the prescription dose was 67.15% (26–86%) and median V95 dose for ITV was 4231cGy (1735cGy‐5290cGy).Conclusion:Images used in lung SBRT are critical for treatment quality; FB and MIP images did not compensate target movement, therefore 4DCT images should be obtained for all patients undergoing lung SBRT or the safety margins should be adjusted.

SU-C-9A-06: The Impact of CT Image Used for Attenuation Correction in 4D-PET

Purpose: To evaluate the appropriateness of using 3D non-gated CT image for attenuation correction (AC) in a 4D-PET (gated PET) imaging protocol used in radiotherapy treatment planning simulation. Methods: The 4D-PET imaging protocol in a Siemens PET/CT simulator (Biograph mCT, Siemens Medical Solutions, Hoffman Estates, IL) was evaluated. CIRS Dynamic Thorax Phantom (CIRS Inc., Norfolk, VA) with a moving glass sphere (8 mL) in the middle of its thorax portion was used in the experiments. The glass was filled with 18F-FDG and was in a longitudinal motion derived from a real patient breathing pattern. Varian RPM system (Varian Medical Systems, Palo Alto, CA) was used for respiratory gating. Both phase-gating and amplitude-gating methods were tested. The clinical imaging protocol was modified to use three different CT images for AC in 4D-PET reconstruction: first is to use a single-phase CT image to mimic actual clinical protocol (single-CT-PET); second is to use the average intensity projection CT (AveIP-CT) derived from 4D-CT scanning (AveIP-CT-PET); third is to use 4D-CT image to do the phase-matched AC (phase-matching- PET). Maximum SUV (SUVmax) and volume of the moving target (glass sphere) with threshold of 40% SUVmax were calculated for comparison between 4D-PET images derived with different AC methods. Results: The SUVmax varied 7.3%±6.9% over the breathing cycle in single-CT-PET, compared to 2.5%±2.8% in AveIP-CT-PET and 1.3%±1.2% in phasematching PET. The SUVmax in single-CT-PET differed by up to 15% from those in phase-matching-PET. The target volumes measured from single- CT-PET images also presented variations up to 10% among different phases of 4D PET in both phase-gating and amplitude-gating experiments. Conclusion: Attenuation correction using non-gated CT in 4D-PET imaging is not optimal process for quantitative analysis. Clinical 4D-PET imaging protocols should consider phase-matched 4D-CT image if available to achieve better accuracy.