title: Comparison of IGRT registration strategies for optimal coverage of primary lung tumors and involved nodes based on multiple four-dimensional CT scans obtained throughout the radiotherapy course.
abstract: OBJECTIVE
  To investigate the impact of primary tumor and involved lymph node (LN) geometry (centroid, shape, volume) on internal target volume (ITV) throughout treatment for locally advanced non-small cell lung cancer using weekly four-dimensional computed tomography (4DCT).
  
  
  METHODS
  Eleven patients with advanced non-small cell lung cancer were treated using image-guided radiotherapy with acquisition of weekly 10-Phase 4DCTs (n = 51). Initial ITV was based on planning 4DCT. Master-ITV incorporated target geometry across the entire treatment (all 4DCTs). Geographic miss was defined as the % Master-ITV positioned outside of the initial planning ITV after registration is complete. Registration strategies considered were bony (B), primary tumor soft tissue alone (T), and registration based on primary tumor and involved LNs (T_LN).
  
  
  RESULTS
  The % geographic miss for the primary tumor, mediastinal, and hilar lymph nodes based on each registration strategy were (1) B: 30%, 30%, 30%; (2) T: 21%, 40%, 36%; and (3) T_LN: 26%, 26%, 27%. Mean geographic expansions to encompass 100% of the primary tumor and involved LNs were 1.2 ± 0.7 cm and 0.8 ± 0.3 cm, respectively, for B and T_LN. Primary and involved LN expansions were 0.7 ± 0.5 cm and 1.1 ± 0.5 cm for T.
  
  
  CONCLUSIONS
  T is best for solitary targets. When treatments include primary tumor and LNs, B and T_LN provide more comprehensive geographic coverage. We have identified high % geographic miss when considering multiple registration strategies. The dosimetric implications are the subject of future study.
authors.affiliation: Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, MI 48073, USA.
authors.forename: Nasiruddin
authors.initials: N
authors.lastname: Mohammed
authors.forename: Larry
authors.initials: L
authors.lastname: Kestin
authors.forename: Inga
authors.initials: I
authors.lastname: Grills
authors.forename: Chirag
authors.initials: C
authors.lastname: Shah
authors.forename: Carri
authors.initials: C
authors.lastname: Glide-Hurst
authors.forename: Di
authors.initials: D
authors.lastname: Yan
authors.forename: Dan
authors.initials: D
authors.lastname: Ionascu
mesh_terms: D000368:Aged; D002289:Carcinoma, Non-Small-Cell Lung / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000473:pathology / Q000532:radiotherapy*; D005260:Female; D056973:Four-Dimensional Computed Tomography; D006801:Humans; D008175:Lung Neoplasms / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000473:pathology / Q000532:radiotherapy*; D008198:Lymph Nodes / Q000000981:diagnostic imaging* / Q000473:pathology; D008297:Male; D008482:Mediastinum / Q000000981:diagnostic imaging; D008875:Middle Aged; D009068:Movement; D011446:Prospective Studies; D011880:Radiotherapy Planning, Computer-Assisted / Q000379:methods*; D061089:Radiotherapy, Image-Guided / Q000379:methods*