Accuracy of daily image guidance for hypofractionated liver radiotherapy with active breathing control.
OBJECTIVE
A six-fraction, high-precision radiotherapy protocol for unresectable liver cancer has been developed in which active breathing control (ABC) is used to immobilize the liver and daily megavoltage (MV) imaging and repositioning is used to decrease geometric uncertainties. We report the accuracy of setup in the first 20 patients consecutively treated using this approach.


METHODS
After setup using conventional skin marks and lasers, orthogonal MV images were acquired with the liver immobilized using ABC. The images were aligned to reference digitally reconstructed radiographs using the diaphragm for craniocaudal (CC) alignment and the vertebral bodies for anterior-posterior (AP) and mediolateral (ML) alignment. Adjustments were made for positioning errors >3 mm. Verification imaging was repeated after repositioning to assess for residual positioning error. Offline image matching was conducted to determine the setup accuracy using this approach compared with the initial setup error before repositioning. Real-time beam's-eye-view MV movies containing an air-diaphragm interface were also evaluated.


RESULTS
A total of 405 images were evaluated from 20 patients. Repositioning occurred in 109 of 120 fractions because of offsets >3 mm. Three to eight beam angles, with up to four segments per field, were used for each isocenter. Breath holds of up to 27 s were used for imaging and treatment. The average time from the initial verification image to the last treatment beam was 21 min. Image guidance and repositioning reduced the population random setup errors (sigma) from 6.5 mm (CC), 4.2 mm (ML), and 4.7 mm (AP) to 2.5 mm (CC), 2.8 mm (ML), and 2.9 mm (AP). The average individual random setup errors (sigma) were reduced from 4.5 mm (CC), 3.2 mm (AP), and 2.5 mm (ML) to 2.2 mm (CC), 2.0 mm (AP), and 2.0 mm (ML). The standard deviation of the distribution of systematic deviations (Sigma) was also reduced from 5.1 mm (CC), 3.4 mm (ML), and 3.1 mm (AP) to 1.4 mm (CC), 2.0 mm (ML), and 1.9 mm (AP) with image guidance and repositioning. The average absolute systematic errors were reduced from 4.1 mm (CC), 2.4 mm (AP), and 3.1 (ML) to 1.1 mm (CC), 1.3 mm (AP), and 1.6 mm (ML). Analysis of 52 real-time beam's-eye-view MV movies revealed an average absolute CC offset in diaphragm position of 1.9 mm.


CONCLUSIONS
Image guidance with orthogonal MV imaging and ABC for stereotactic body radiotherapy for liver cancer is feasible, improving setup accuracy compared with ABC without daily imaging and repositioning.
Department of Radiation Oncology, University of Toronto, Princess Margaret Hospital, 610 University Avenue, Toronto, Ontario M5G 2M9, Canada. laura.dawson@rmp.uhn.on.ca
Laura A
LA
Dawson
Cynthia
C
Eccles
Jean-Pierre
JP
Bissonnette
Kristy K
KK
Brock
D006528:Carcinoma, Hepatocellular / Q000000981:diagnostic imaging / Q000532:radiotherapy; D018281:Cholangiocarcinoma / Q000000981:diagnostic imaging / Q000532:radiotherapy; D005240:Feasibility Studies; D006801:Humans; D007091:Image Processing, Computer-Assisted / Q000379:methods; D007103:Immobilization; D008113:Liver Neoplasms / Q000000981:diagnostic imaging / Q000532:radiotherapy* / Q000556:secondary; D009068:Movement; D011859:Radiography; D011880:Radiotherapy Planning, Computer-Assisted / Q000379:methods*; D020266:Radiotherapy, Conformal; D012119:Respiration