The purpose of this study was to provide guidance in developing and implementing a process for the accurate delivery of free breathing respiratory amplitude-gated treatments.Methods: A phase-based 4DCT scan is acquired at time of simulation and motion is evaluated to determine the exhale phases that minimize respiratory motion to an acceptable level. A phase subset average CT is then generated for treatment planning and a tracking structure is contoured to indicate the location of the target or a suitable surrogate over the planning phases. Prior to treatment delivery, a 4DCBCT is acquired and a phase subset average is created to coincide with the planning phases for an initial match to the planning CT. Fluoroscopic imaging is then used to set amplitude gate thresholds corresponding to when the target or surrogate is in the tracking structure. The final imaging prior to treatment is an amplitude-gated CBCT to verify both the amplitude gate thresholds and patient positioning. An amplitude-gated treatment is then delivered. This technique was commissioned using an in-house lung motion phantom and film measurements of a simple two-field 3D plan.Results: The accuracy of 4DCBCT motion and target position measurements were validated relative to 4DCT imaging. End to end testing showed strong agreement between planned and film measured dose distributions. Robustness to interuser variability and changes in respiratory motion were demonstrated through film measurements. Conclusions:The developed workflow utilizes 4DCBCT, respiratory-correlated fluoroscopy, and gated CBCT imaging in an efficient and sequential process to ensure the accurate delivery of free breathing respiratory-gated treatments. | INTRODUCTIONRespiratory motion management is an important strategy to account for breathing-induced target motion during radiation therapy. 1 If not considered during both the treatment planning and delivery processes, respiratory motion can lead to artifacts and target volumes that do not adequately encompass the target. Active respiratory motion management techniques can be used to minimize target motion during treatment delivery, allowing for a reduction in target volumes and improved normal tissue sparing. Such techniques include abdominal compression, 2 breath hold, 3 and free breathing phase or amplitude gating. 4 Many thoracic and abdominal sites are susceptible to substantial motion, with abdominal and lower lung lesion motion often measured to be greater than 1 cm. 5,6 Inter-and intrafraction changes in target motion magnitude greater than 5 mm have been

For total skin electron (TSE) beam radiation therapy, the anterior eye and conjunctiva can be protected with eye shields to prevent keratitis, xerophthalmia, and cataractogenesis. Conventional metal eye shields can reduce patient balance by obscuring vision and thus increasing the risk for falls. We report on the design, fabrication, and clinical use of transparent acrylic eye shields for TSE. Methods: The primary design goals were a seven-fold reduction in the dose to the anterior eye and conjunctiva to meet published dose-recommendations, preservation of vision for the wearer, and biocompatibility for external use. Resembling thick swim goggles, the design features 23 mm thick acrylic lenses that are mounted in a 3-D printed support structure that conforms to the eye socket and can be worn with a strap. Dose measurements were performed in a simulated Stanford-technique treatment with an anthropomorphic phantom using Gafchromic EBT film Results: The transparent eye shields were manufactured using a 3D-printer and CNC-machine. Based on measurements from the simulated treatments for each of the eye shields, the eye shields provided a 12-fold reduction in dose to the lens. After use in more than 200 fractions, the shields were well tolerated by patients, and there were no reports of any incidents or adverse events. Conclusion: Transparent TSE eye shields are able to reduce the dose to the eyes while maintaining vision during treatment at a reasonable cost.