title: CT evaluation of patient deep inspiration self-breath-holding: how precisely can patients reproduce the tumor position in the absence of respiratory monitoring devices?
abstract: The aim of the present study was to evaluate the reproducibility of tumor position under patient deep inspiration self-breath-holding in the absence of respiratory monitoring devices, as well as to compare the reproducibility of deep inspiration self-breath-holding on the verbal command of a radiation technologist (Passive mode) with that initiated by patients' own estimation (Active mode). Twenty patients with lung cancer were shown how the tumor and diaphragm move during the respiration cycle. Patients were instructed to hold their breath during deep inspiration and reproduce identical tumor position as well as possible either by the Active mode or by the Passive mode. After patients had practiced self-breath-holding during deep inspiration, a set of three CT scans was obtained for each of the two modes of self-breath-holding (6 CT scans total) to obtain randomly timed images of 2 mm thickness in the vicinity of the tumor. The first three scans were performed during breath-hold using the Active mode, and next three scans were using the Passive mode. Maximum difference in tumor position for the three CT scans was then calculated along three axes: cranial-caudal (C-C); anterior-posterior (A-P); and right-left (R-L). In the 20 patients who underwent analysis of self-breath-holding, mean maximum difference in tumor position obtained under breath-hold using the Active and the Passive modes were: 2.2 and 3.1 mm along the C-C axis; 1.4 and 2.4 mm along the A-P axis; and 1.3 and 2.2 mm along the R-L axis, respectively. These differences in all axes were significantly smaller (p<0.05) for the Active mode than for the Passive mode. Most tumors displayed maximal respiratory movement along the C-C axis, and minimal movement along the R-L axis, but tumors located in the upper lung displayed maximal movement along the A-P axis. Significant correlation (p<0.05) was observed between differences along three axes in either mode of breath-hold. In conclusion, the reproducibility of tumor position under self-breath-holding by patients during deep inspiration after sufficient practice and in the absence of respiratory monitoring devices was satisfactorily accurate, and differences in tumor position were smaller under breath-holding using the Active mode than using the Passive mode. We believe this new technique is likely to prove extremely useful for the irradiation of lung tumors with a small internal margin and for reduced proportion of high-dose irradiated normal lung to total lung volume.
authors.affiliation: Department of Radiology, Yamanashi Medical University, 1110 Shimokato Tamaho-cho, Nakakomna-gun, Yamanashi, 409-3898, Japan. honishi@res.yamanashi-med.ac.jp
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Onishi
authors.forename: Kengo
authors.initials: K
authors.lastname: Kuriyama
authors.forename: Takafumi
authors.initials: T
authors.lastname: Komiyama
authors.forename: Shiho
authors.initials: S
authors.lastname: Tanaka
authors.forename: Junko
authors.initials: J
authors.lastname: Ueki
authors.forename: Naoki
authors.initials: N
authors.lastname: Sano
authors.forename: Tsutomu
authors.initials: T
authors.lastname: Araki
authors.forename: Satoshi
authors.initials: S
authors.lastname: Ikenaga
authors.forename: Yoshihito
authors.initials: Y
authors.lastname: Tateda
authors.forename: Yoshihito
authors.initials: Y
authors.lastname: Aikawa
mesh_terms: D016477:Artifacts; D006801:Humans; D008168:Lung / Q000000981:diagnostic imaging*; D008175:Lung Neoplasms / Q000000981:diagnostic imaging* / Q000532:radiotherapy; D009068:Movement; D011187:Posture; D011786:Quality Control; D011859:Radiography; D011874:Radiometry / Q000379:methods*; D011880:Radiotherapy Planning, Computer-Assisted / Q000379:methods*; D015203:Reproducibility of Results; D012119:Respiration; D012680:Sensitivity and Specificity; D013382:Subtraction Technique