title: Daily targeting of intrahepatic tumors for radiotherapy.
abstract: BACKGROUND
  A system has been developed for daily targeting of intrahepatic tumors using a combination of ventilatory immobilization, in-room diagnostic imaging, and on-line setup adjustment. By reducing geometric position uncertainty, as well as organ movement, this system permits reduction of margins and thus potentially higher treatment doses. This paper reports our initial experience treating 8 patients with focal liver tumors using this system.
  
  
  METHODS
  The system includes diagnostic X-ray tubes mounted on the wall and ceiling of a treatment room, an active matrix flat panel imager, in-room control for image acquisition and setup adjustment, and a ventilatory immobilization system via active breathing control (ABC). Eight patients participated in the study, two using an early prototype ABC unit, and the remaining six with a commercial ABC system and improved setup measurement tools. Treatment margins were reduced, and dose consequently increased because of increased confidence in target position under this protocol. After daily setup via skin marks, orthogonal radiographs were acquired at suspended ventilation. The images were aligned to the CT model using the diaphragm for inferior-superior (IS) alignment, and the skeleton for left-right (LR) and anterior-posterior (AP) alignment. Adjustments were made for positioning errors greater than a threshold (3 or 5 mm). After treatment, retrospective analysis determined the final setup accuracy, as well as the error in initial setup measurement performed before setup adjustment.
  
  
  RESULTS
  Two hundred sixty-two treatment fractions were delivered on eight patients, with 171 treatments requiring repositioning. Typical treatment times were 25-30 min. Patients were able to tolerate ABC throughout the course of treatment. Breath holds up to 35 s long were used for treatment. The use of on-line imaging and setup adjustment reduced setup errors (sigma) from 4.0 mm (LR), 6.7 mm (IS), and 3.8 mm (AP) to 2.1 mm (LR), 3.5 mm (IS), and 2.3 mm (AP). Prescribed doses were increased using this system by an average of 5 Gy.
  
  
  CONCLUSIONS
  Daily targeting of intrahepatic targets has been demonstrated to be feasible. The potential for reduction in treatment margin and consequential safe dose escalation has been demonstrated, while maintaining reasonable treatment delivery times.
authors.affiliation: Department of Radiation Oncology, University of Michigan Health Systems, Ann Arbor, MI 48109-0010, USA. jbalter@umich.edu
authors.forename: James M
authors.initials: JM
authors.lastname: Balter
authors.forename: Kristy K
authors.initials: KK
authors.lastname: Brock
authors.forename: Dale W
authors.initials: DW
authors.lastname: Litzenberg
authors.forename: Daniel L
authors.initials: DL
authors.lastname: McShan
authors.forename: Theodore S
authors.initials: TS
authors.lastname: Lawrence
authors.forename: Randall
authors.initials: R
authors.lastname: Ten Haken
authors.forename: Cornelius J
authors.initials: CJ
authors.lastname: McGinn
authors.forename: Kwok L
authors.initials: KL
authors.lastname: Lam
authors.forename: Laura A
authors.initials: LA
authors.lastname: Dawson
mesh_terms: D019583:Dose Fractionation, Radiation; D004867:Equipment Design; D006801:Humans; D008113:Liver Neoplasms / Q000000981:diagnostic imaging / Q000532:radiotherapy*; D009068:Movement; D055585:Physical Phenomena; D010825:Physics; D011880:Radiotherapy Planning, Computer-Assisted / Q000379:methods*; D012119:Respiration; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed