title: An evaluation of two internal surrogates for determining the three-dimensional position of peripheral lung tumors.
abstract: OBJECTIVE
  Both carina and diaphragm positions have been used as surrogates during respiratory-gated radiotherapy. We studied the correlation of both surrogates with three-dimensional (3D) tumor position.
  
  
  METHODS
  A total of 59 repeat artifact-free four-dimensional (4D) computed tomography (CT) scans, acquired during uncoached breathing, were identified in 23 patients with Stage I lung cancer. Repeat scans were co-registered to the initial 4D CT scan, and tumor, carina, and ipsilateral diaphragm were manually contoured in all phases of each 4D CT data set. Correlation between positions of carina and diaphragm with 3D tumor position was studied by use of log-likelihood ratio statistics. Models to predict 3D tumor position from internal surrogates at end inspiration (EI) and end expiration (EE) were developed, and model accuracy was tested by calculating SDs of differences between predicted and actual tumor positions.
  
  
  RESULTS
  Motion of both the carina and diaphragm significantly correlated with tumor motion, but log-likelihood ratios indicated that the carina was more predictive for tumor position. When craniocaudal tumor position was predicted by use of craniocaudal carina positions, the SDs of the differences between the predicted and observed positions were 2.2 mm and 2.4 mm at EI and EE, respectively. The corresponding SDs derived with the diaphragm positions were 3.7 mm and 3.9 mm at EI and EE, respectively. Prediction errors in the other directions were comparable. Prediction accuracy was similar at EI and EE.
  
  
  CONCLUSIONS
  The carina is a better surrogate of 3D tumor position than diaphragm position. Because residual prediction errors were observed in this analysis, additional studies will be performed using audio-coached scans.
authors.affiliation: Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands. f.spoelstra@vumc.nl
authors.forename: Femke O B
authors.initials: FO
authors.lastname: Spoelstra
authors.forename: John R
authors.initials: JR
authors.lastname: van Sörnsen de Koste
authors.forename: Andrew
authors.initials: A
authors.lastname: Vincent
authors.forename: Johan P
authors.initials: JP
authors.lastname: Cuijpers
authors.forename: Ben J
authors.initials: BJ
authors.lastname: Slotman
authors.forename: Suresh
authors.initials: S
authors.lastname: Senan