title: Defining the margins in the radical radiotherapy of non-small cell lung cancer (NSCLC) with active breathing control (ABC) and the effect on physical lung parameters.
abstract: BACKGROUND
  The effectiveness of ABC has been traditionally measured as the reduction in internal margin (IM) within the planning target volume (PTV). Not to overestimate the benefit of ABC, the effect of patient movement during treatment also needs to be taken into account. We determined the IM and set-up error with ABC and the effect on physical lung parameters compared to standard margins used with free breathing. We also assessed interfraction oesophageal movement to determine a planning organ at risk volume (PRV).
  
  
  METHODS
  Two sequential studies were performed using ABC in NSCLC patients suitable for radical radiotherapy (RT). Twelve out of 14 patients in Study 1 had tumours visible fluoroscopically and had intrafraction tumour movement assessed with and without ABC. Sixteen patients were recruited to Study 2 and had interfraction tumour movement measured using ABC in a moderate deep inspiration breath-hold, of these 7 patients also had interfraction oesophageal movement recorded. Interfraction movement was assessed by CT scan prior to and in the middle and final week of RT. Displacement of the tumour centre of mass and oesophageal borders relative to the first scan provided a measure of movement. Set-up error was measured in 9 patients treated with an in-house lung board adapted for the ABC device. Combining movement and set-up errors determined PTV and PRV margins with ABC. The effect of ABC on mean lung dose (MLD), lung V20 and V13 was calculated.
  
  
  RESULTS
  ABC in a moderate deep inspiration breath-hold was tolerated in 25 out of 30 patients (83%) in Study 1 and 2. The random contribution of periodic tumour motion was reduced by 90% in the y direction with ABC compared to free-breathing. The magnitude of motion reduction was less in the x and z direction. Combining the systematic and random set-up error in quadrature with the systematic and random intrafraction and interfraction tumour variations with ABC results in a PTV margin of 8.3mm in the x direction, 12.0mm in the y direction and 9.8mm in the z direction. There was a relative mean reduction in MLD, lung V20 and V13 of 25%, 21% and 18% with the ABC PTV compared to a free-breathing PTV. Oesophageal movement combined with set-up error resulted in an isotropic PRV of 4.7 mm.
  
  
  CONCLUSIONS
  The reduction in PTV size with ABC resulted in an 18-25% relative reduction in physical lung parameters. PTV margin reduction has the potential to spare normal lung and allow dose-escalation if coupled with image-guided RT. The oesophageal PRV needs to be considered when irradiating central disease and is of increasing importance with altered RT fractionation and concomitant chemoradiation schedules. Further reductions in PTV and PRV may be possible if patient set-up error was minimised, confirming that attention to patient immobilisation is as important as attempts to control tumour motion.
authors.affiliation: The Academic Unit of Radiotherapy and Oncology, The Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK. nikip@doctors.org.uk
authors.forename: Niki
authors.initials: N
authors.lastname: Panakis
authors.forename: Helen A
authors.initials: HA
authors.lastname: McNair
authors.forename: Judith A
authors.initials: JA
authors.lastname: Christian
authors.forename: Ruheena
authors.initials: R
authors.lastname: Mendes
authors.forename: J Richard N
authors.initials: JR
authors.lastname: Symonds-Tayler
authors.forename: Clifford
authors.initials: C
authors.lastname: Knowles
authors.forename: Philip M
authors.initials: PM
authors.lastname: Evans
authors.forename: James
authors.initials: J
authors.lastname: Bedford
authors.forename: Michael
authors.initials: M
authors.lastname: Brada
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002289:Carcinoma, Non-Small-Cell Lung / Q000000981:diagnostic imaging / Q000473:pathology / Q000532:radiotherapy*; D005260:Female; D005471:Fluoroscopy; D006801:Humans; D007103:Immobilization; D008175:Lung Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology / Q000532:radiotherapy*; D008297:Male; D008875:Middle Aged; D011880:Radiotherapy Planning, Computer-Assisted; D012119:Respiration; D018709:Statistics, Nonparametric; D014057:Tomography, X-Ray Computed