Effects of organ motion on IMRT treatments with segments of few monitor units

• Published in: Medical physics (Lancaster) Vol. 34; no. 3; pp. 923 - 934
• Main Authors: Seco, J., Sharp, G. C., Turcotte, J., Gierga, D., Bortfeld, T., Paganetti, H.
• Format: Journal Article
• Language: English
• Published: United States American Association of Physicists in Medicine 01-03-2007
• Subjects: Anatomy; Ancillary equipment; BEAMS; biological organs; BIOLOGICAL RADIATION EFFECTS; cancer; Conformal radiation treatment; DAILY VARIATIONS; Dose Fractionation; DOSIMETRY; ERRORS; Humans; hypo‐fractionation; IGRT; Intensity modulated radiation therapy; ionisation chambers; IONIZATION CHAMBERS; Lungs; Models, Statistical; Motion; motion average‐dose; Movement; Multileaf collimators; NEOPLASMS; OPTIMIZATION; organ motion; ORGANS; Particle Accelerators; PATIENTS; pneumodynamics; Probability; Probability density functions; RADIATION DOSES; radiation therapy; Radiation treatment; RADIOLOGY AND NUCLEAR MEDICINE; Radiometry; RADIOTHERAPY; Radiotherapy - instrumentation; Radiotherapy - methods; Radiotherapy Dosage; Radiotherapy Planning, Computer-Assisted - methods; Radiotherapy, Intensity-Modulated - methods; RESPIRATION; SIMULATION; small MU segments; Treatment strategy; tumours; organ motion; IGRT; motion average-dose; small MU segments; hypo-fractionation
• ISSN: 0094-2405; 2473-4209
• DOI: 10.1118/1.2436972

Interplay between organ (breathing) motion and leaf motion has been shown in the literature to have a small dosimetric impact for clinical conditions (over a 30 fraction treatment). However, previous studies did not consider the case of treatment beams made up of many few-monitor-unit (MU) segments, where the segment delivery time
(
1
–
2
s
)
is of the order of the breathing period
(
3
–
5
s
)
. In this study we assess if breathing compromises the radiotherapy treatment with IMRT segments of low number of MUs. We assess (i) how delivered dose varies, from patient to patient, with the number of MU per segment, (ii) if this delivered dose is identical to the average dose calculated without motion over the path of the motion, and (iii) the impact of the daily variation of the delivered dose as a function of MU per segment. The organ motion was studied along two orthogonal directions, representing the left-right and cranial-caudal directions of organ movement for a patient setup in the supine position. Breathing motion was modeled as
sin
(
x
)
,
sin
4
(
x
)
, and
sin
6
(
x
)
, based on functions used in the literature to represent organ motion. Measurements were performed with an ionization chamber and films. For a systematic study of motion effects, a MATLAB simulation was written to model organ movement and dose delivery. In the case of a single beam made up of one single segment, the dose delivered to point in a moving target over 30 fractions can vary up to 20% and 10% for segments of
10
MU
and
20
MU
, respectively. This dose error occurs because the tumor spends most of the time near the edges of the radiation beam. In the case of a single beam made of multiple segments with low MU, we observed 2.4%, 3.3%, and 4.3% differences, respectively, for
sin
(
x
)
,
sin
4
(
x
)
, and
sin
6
(
x
)
motion, between delivered dose and motion-averaged dose for points in the penumbra region of the beam and over 30 fractions. In approximately 5–10% of the cases, differences between the motion-averaged dose and the delivered 30-fraction dose could reach 6%, 8% and 10–12%, respectively for
sin
(
x
)
,
sin
4
(
x
)
, and
sin
6
(
x
)
motion. To analyze a clinical IMRT beam, two patient plans were randomly selected. For one of the patients, the beams showed a likelihood of up to 25.6% that the delivered dose would deviate from the motion-averaged dose by more than 1%. For the second patient, there was a likelihood of up to 62.8% of delivering a dose that differs by more than 1% from the motion-averaged dose and a likelihood of up to
∼
30
%
for a 2% dose error. For the entire five-beam IMRT plan, statistical averaging over the beams reduces the overall dose error between the delivered dose and the motion-averaged dose. For both patients there was a likelihood of up to 7.0% and 33.9% that the dose error was greater than 1%, respectively. For one of the patients, there was a 12.6% likelihood of a 2% dose error. Daily intrafraction variation of the delivered dose of more than 10% is non-negligible and can potentially lead to biological effects. We observed [for
sin
(
x
)
,
sin
4
(
x
)
, and
sin
6
(
x
)
] that below
10
–
15
MU
leads to large daily variations of the order of 15–35%. Therefore, for small MU segments, non-negligible biological effects can be incurred. We conclude that for most clinical cases the effects may be small because of the use of many beams, it is desirable to avoid low-MU segments when treating moving targets. In addition, dose averaging may not work well for hypo-fractionation, where fewer fractions are used. For hypo-fractionation, PDF modeling of the tumor motion in IMRT optimization may not be adequate.