Using intra-fractional cone-beam CT (CBCT) to evaluate the amplitude changes and baseline shifts of respiratory motion in liver stereotactic body radiation therapy (SBRT). Methods: The amplitude changes and baseline shifts of respiratory motion for 24 liver patients were evaluated by the four-dimensional (4D) CT, inter-and intra-fractional CBCT. The difference of the average liver position errors among all treatment fractions and the 4D CT representthe baseline shifts. According to the baseline shifts, the ITV to PTV margin was recalculated and the plan was re-designed to compare the dosimetric variation. Results: The systematic and random errors of the baseline shifts for intra-fractional CBCT in the left-right (LR), superior-inferior (SI), and anterior-posterior (AP) directions were 0.99/1.60 mm, 2.03/2.46 mm, and 1.02/2.07 mm, respectively. The new ITV to PTV margins should be 4.0 mm, 7.0 mm, and 4.0 mm, respectively. The amplitude change of motion between the 4D CT and the intra-fractional CBCT was 1.03 ± 4.35 mm, with 31% of fractions exceeding 5 mm. To achieve the same dose coverage of the new PTV, the D mean , V50, V40, V30, V25 of normal liver and maximum dose of the duodenum were significantly different. Conclusions: Significant amplitude changes and baseline shifts of motion occurred during dose delivery compared with those in 4D CT. Using the ITV to PTV margin of 4.0 mm (LR), 7.0 mm (SI), and 4.0 mm (AP) can ensure the target dose coverage and keep the dose constrain of normal tissues at an acceptable level.

Abstract Purpose: To evaluate the amplitude changes and baseline drift of respiratory motion in liver stereotactic body radiation therapy based on intra-fraction cone beam CT (CBCT).Materials and methods: Twenty-four liver SBRT patients underwent a four-dimensional computed tomography (4D CT) scan, inter-fraction cone-beam computed tomography (CBCT), and intra-fraction CBCT to evaluate the amplitude changes and baseline drift of respiratory motion. The amplitude changes were defined as the variations between the amplitude measured in the 4D CT and those measured with fluoroscopy in inter- and intra-fraction CBCT. The baseline drifts were defined as the difference between the liver position errors and the setup errors in inter- and intra-fraction CBCT. Manual registration of the liver contour was performed to obtain liver position errors, and bone registration was performed to obtain setup errors. Meanwhile, the correlation among the liver position errors, the relative diaphragm position, and the amplitude changes was evaluated. Results: The systematic and random errors of the baseline drifts for intra-fraction CBCT in the medial-lateral (ML), superior-inferior (SI), and anterior-posterior (AP) views were 0.99 and 1.6 mm, 2.03 and 2.46 mm, and 1.02 and 2.07 mm, respectively. The corresponding PTV margin was 3.61 mm, 6.8 mm, and 4.00 mm, respectively. The amplitude variation ranged from -169.33% to 65.47% in inter-fraction CBCT and from -171.04% to 60.00% in intra-fraction CBCT. Inter-fraction liver position errors were significantly related to the setup errors. The relative diaphragm position was not statistically related to the baseline drifts in the inter-fraction nor in the intra-fraction. Conclusions: Using intra-fraction CBCT, significant amplitude variations and baseline drifts of respiratory motion were found compared with those in 4D CT. The relative diaphragm position in a single breathing cycle cannot reflect the liver position during dose delivery. At least a 6.8 mm PTV margin in the SI direction is recommended to compensate for the baseline drift.