A review on the clinical implementation of respiratory-gated radiation therapy

Abstract

Respiratory-gated treatment techniques have been introduced into the radiation oncology practice to manage target or organ motions. This paper will review the implementation of this type of gated treatment technique where the respiratory cycle is determined using an external marker. The external marker device is placed on the abdominal region between the xyphoid process and the umbilicus of the patient. An infrared camera tracks the motion of the marker to generate a surrogate for the respiratory cycle. The relationship, if any, between the respiratory cycle and the movement of the target can be complex. The four-dimensional computed tomography (4DCT) scanner is used to identify this motion for those patients that meet three requirements for the successful implementation of respiratory-gated treatment technique for radiation therapy. These requirements are (a) the respiratory cycle must be periodic and maintained during treatment, (b) the movement of the target must be related to the respiratory cycle, and (c) the gating window can be set sufficiently large to minimise the overall treatment time or increase the duty cycle and yet small enough to be within the gate. If the respiratory-gated treatment technique is employed, the end-expiration image set is typically used for treatment planning purposes because this image set represents the phase of the respiratory cycle where the anatomical movement is often the least for the longest time. Contouring should account for tumour residual motion, setup uncertainty, and also allow for deviation from the expected respiratory cycle during treatment. Respiratory-gated intensity-modulated radiation therapy (IMRT) treatment plans must also be validated prior to treatment. Quality assurance should be performed to check for positional changes and the output in association with the motion-gated technique. To avoid potential treatment errors, radiation therapist (radiographer) should be regularly in-serviced and made aware of the need to invoke the gating feature when prescribed for selected patients.

Quality Assurance for Respiratory-Gated Radiotherapy Using the Real-Time Tumor-Tracking Radiotherapy System

“…The differences for gating were ≤1.8 mm. Saw et al reported that differences in isodose levels between the measured and planned dose distribution should be within 3.0 mm in the high-dose region using respiratory-gated IMRT delivery [7]. The International Commission on Radiation Units and Measurement report 42 has recommended that the distance-to-agreement for the high dose region was ≤2.0 mm [14].…”

“…Several investigators have reported the quality assurance (QA) for respiratory-gated RT using an external signal [7] [8]. Our group has aimed to perform the respiratory-gated RT using the fiducial marker for lung cancer with high accuracy.…”

Performance evaluation of gated volumetric modulated arc therapy

“…Adding gating (beam holds) to VMAT increases the complexity further. Therefore it is important to evaluate the feasibility and the dosimetric accuracy of the gated VMAT before its clinical use (1,5) . The gamma agreement index in table 1 does not provide any clinically relevant information about the results (13) , whereas COMPASS system provides the signi-icance of error in PTV and as well as in OAR's (14)(15)(16)(17)(18) .…”

“…These treatment techniques target radiation doses precisely to the shape of tumors, reducing toxicity and side-effects. But for tumors in the thorax and abdomen region, respiratory motion is a limiting factor, which will degrade the effectiveness of conformal radiotherapy (1,2) .…”

“…In-sequence, dose delivery system temporarily stops gantry and MLC movement. Due to complex delivery of gated VMAT, it is essential to evaluate and verify the accuracy of the system before its clinical use (1) .…”