title: Use of a realistic breathing lung phantom to evaluate dose delivery errors.
abstract: OBJECTIVE
  To compare the effect of respiration-induced motion on delivered dose (the interplay effect) for different treatment techniques under realistic clinical conditions.
  
  
  METHODS
  A flexible resin tumor model was created using rapid prototyping techniques based on a computed tomography (CT) image of an actual tumor. Twenty micro-MOSFETs were inserted into the tumor model and the tumor model was inserted into an anthropomorphic breathing phantom. Phantom motion was programed using the motion trajectory of an actual patient. A four-dimensional CT image was obtained and several treatment plans were created using different treatment techniques and planning systems: Conformal (Eclipse), step-and-shoot intensity-modulated radiation therapy (IMRT) (Pinnacle), step-and-shoot IMRT (XiO), dynamic IMRT (Eclipse), complex dynamic IMRT (Eclipse), hybrid IMRT [60% conformal, 40% dynamic IMRT (Eclipse)], volume-modulated are therapy (VMAT) [single-arc (Eclipse)], VMAT [double-arc (Eclipse)], and complex VMAT (Eclipse). The complex plans were created by artificially pushing the optimizer to give complex multileaf collimator sequences. Each IMRT field was irradiated five times and each VMAT field was irradiated ten times, with each irradiation starting at a random point in the respiratory cycle. The effect of fractionation was calculated by randomly summing the measured doses. The maximum deviation for each measurement point per fraction and the probability that 95% of the model tumor had dose deviations less than 2% and 5% were calculated as a function of the number of fractions. Tumor control probabilities for each treatment plan were calculated and compared.
  
  
  RESULTS
  After five fractions, measured dose deviations were less than 2% for more than 95% of measurement points within the tumor model for all plans, except the complex dynamic IMRT, step-and-shoot IMRT (XiO), complex VMAT, and single-arc VMAT plans. Reducing the dose rate of the complex IMRT plans from 600 to 200 MU/min reduced the dose deviations to less than 2%. Dose deviations were less than 5% after five fractions for all plans, except the complex single-arc VMAT plan.
  
  
  CONCLUSIONS
  Rapid prototyping techniques can be used to create realistic tumor models. For most treatment techniques, the dose deviations averaged out after several fractions. Treatments with unusually complicated multileaf collimator sequences had larger dose deviations. For IMRT treatments, dose deviations can be reduced by reducing the dose rate. For VMAT treatments, using two arcs instead of one is effective for reducing dose deviations.
authors.affiliation: Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA. lecourt@mdanderson.org
authors.forename: Laurence E
authors.initials: LE
authors.lastname: Court
authors.forename: Joao
authors.initials: J
authors.lastname: Seco
authors.forename: Xing-Qi
authors.initials: XQ
authors.lastname: Lu
authors.forename: Kazuyu
authors.initials: K
authors.lastname: Ebe
authors.forename: Charles
authors.initials: C
authors.lastname: Mayo
authors.forename: Dan
authors.initials: D
authors.lastname: Ionascu
authors.forename: Brian
authors.initials: B
authors.lastname: Winey
authors.forename: Nikos
authors.initials: N
authors.lastname: Giakoumakis
authors.forename: Michalis
authors.initials: M
authors.lastname: Aristophanous
authors.forename: Ross
authors.initials: R
authors.lastname: Berbeco
authors.forename: Joerg
authors.initials: J
authors.lastname: Rottman
authors.forename: Madeleine
authors.initials: M
authors.lastname: Bogdanov
authors.forename: Deborah
authors.initials: D
authors.lastname: Schofield
authors.forename: Tania
authors.initials: T
authors.lastname: Lingos
mesh_terms: D000465:Algorithms; D019583:Dose Fractionation, Radiation; D006801:Humans; D021621:Imaging, Three-Dimensional; D008168:Lung / Q000000981:diagnostic imaging* / Q000473:pathology; D019300:Medical Errors / Q000517:prevention & control*; D015233:Models, Statistical; D009038:Motion; D019047:Phantoms, Imaging; D011878:Radiotherapy / Q000379:methods*; D050397:Radiotherapy, Intensity-Modulated / Q000379:methods; D015203:Reproducibility of Results; D012119:Respiration; D013997:Time Factors; D014057:Tomography, X-Ray Computed / Q000379:methods