title: Respiratory gating for liver tumors: use in dose escalation.
abstract: OBJECTIVE
  To determine the clinical impact of the Varian Real-Time Position Monitor (RPM) respiratory gating system for treatment of liver tumors.
  
  
  METHODS
  Ten patients with liver tumors were selected for evaluation of this passive system, which tracks motion of reflective markers mounted on the abdomen with an infrared-sensitive camera. At simulation, a fluoroscopic movie, breathing trace, and CT scans synchronized at end-expiration (E-E) and end-inspiration were acquired in treatment position using the RPM system. Organs and gross tumor volume were contoured on each CT. Each organ's positional change between two scan sets was quantified by calculation of the center of volume shift and an "index coefficient," defined as the volume common to the two versions of the organ to the volume included in at least one (intersection/union). Treatment dose was determined by use of normal tissue complication probability calculations and dose-volume histograms. Gated portal images were obtained to monitor gating reproducibility with treatment.
  
  
  RESULTS
  Eight patients received 177 treatments with RPM gating. Average superior-to-inferior (SI) diaphragm motion on initial fluoroscopy was reduced from 22.7 mm without gating to 5.1 mm with gating. Comparing end-inspiration to E-E CT scans, average SI movement of the right diaphragm was 11.5 mm vs. 2.2 mm for two E-E CT scans. For all organs, average E-I SI organ motion was 12.8 mm vs. 2.0 mm for E-E studies. Index coefficients were closer to 1.0 for E-E than end-inspiration scans, indicating gating reproducibility. The average SI displacement of diaphragm apex on gated portal images compared with DRR was 2.3 mm. Treatment was prolonged less than 10 minutes with gating. The reproducible decrease in organ motion with gating enabled reduction in gross tumor volume-to-planning target volume margin from 2 to 1 cm. This allowed for calculated dose increases of 7%-27% (median: 21.3%) in 6 patients and enabled treatment in 2.
  
  
  CONCLUSIONS
  Gating of radiotherapy for liver tumors enables safe margin reduction on tumor volume, which, in turn, may allow for dose escalation.
authors.affiliation: Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA. wagmanr@mskcc.org
authors.forename: Raquel
authors.initials: R
authors.lastname: Wagman
authors.forename: Ellen
authors.initials: E
authors.lastname: Yorke
authors.forename: Eric
authors.initials: E
authors.lastname: Ford
authors.forename: Philippe
authors.initials: P
authors.lastname: Giraud
authors.forename: Gikas
authors.initials: G
authors.lastname: Mageras
authors.forename: Bruce
authors.initials: B
authors.lastname: Minsky
authors.forename: Kenneth
authors.initials: K
authors.lastname: Rosenzweig
mesh_terms: D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000000981:diagnostic imaging / Q000532:radiotherapy*; D003964:Diaphragm / Q000000981:diagnostic imaging; D005260:Female; D006801:Humans; D007103:Immobilization; D008113:Liver Neoplasms / Q000000981:diagnostic imaging / Q000532:radiotherapy*; D008297:Male; D008875:Middle Aged; D009068:Movement; D011879:Radiotherapy Dosage; D015203:Reproducibility of Results; D012119:Respiration; D014057:Tomography, X-Ray Computed / Q000379:methods*