title: Respiration-correlated image guidance is the most important radiotherapy motion management strategy for most lung cancer patients.
abstract: OBJECTIVE
  The purpose of this study was to quantify the effects of four-dimensional computed tomography (4DCT), 4D image guidance (4D-IG), and beam gating on calculated treatment field margins in a lung cancer patient population.
  
  
  METHODS
  Images were acquired from 46 lung cancer patients participating in four separate protocols at three institutions in Europe and the United States. Seven patients were imaged using fluoroscopy, and 39 patients were imaged using 4DCT. The magnitude of respiratory tumor motion was measured. The required treatment field margins were calculated using a statistical recipe (van Herk M, et al. Int J Radiat Oncol Biol Phys 2000;474:1121-1135), with magnitudes of all uncertainties, except respiratory peak-to-peak displacement, the same for all patients, taken from literature. Required margins for respiratory motion management were calculated using the residual respiratory tumor motion for each patient for various motion management strategies. Margin reductions for respiration management were calculated using 4DCT, 4D-IG, and gated beam delivery.
  
  
  RESULTS
  The median tumor motion magnitude was 4.4 mm for the 46 patients (range 0-29.3 mm). This value corresponded to required treatment field margins of 13.7 to 36.3 mm (median 14.4 mm). The use of 4DCT, 4D-IG, and beam gating required margins that were reduced by 0 to 13.9 mm (median 0.5 mm), 3 to 5.2 mm (median 5.1 mm), and 0 to 7 mm (median 0.2 mm), respectively, to a total of 8.5 to 12.4 mm (median 8.6 mm).
  
  
  CONCLUSIONS
  A respiratory management strategy for lung cancer radiotherapy including planning on 4DCT scans and daily image guidance provides a potential reduction of 37% to 47% in treatment field margins. The 4D image guidance strategy was the most effective strategy for >85% of the patients.
authors.affiliation: Department of Science, Systems and Models, Roskilde University, Roskilde, Denmark. korreman@ruc.dk
authors.forename: Stine
authors.initials: S
authors.lastname: Korreman
authors.forename: Gitte
authors.initials: G
authors.lastname: Persson
authors.forename: Ditte
authors.initials: D
authors.lastname: Nygaard
authors.forename: Carsten
authors.initials: C
authors.lastname: Brink
authors.forename: Trine
authors.initials: T
authors.lastname: Juhler-Nøttrup
mesh_terms: D002289:Carcinoma, Non-Small-Cell Lung / Q000000981:diagnostic imaging / Q000532:radiotherapy*; D005471:Fluoroscopy; D056973:Four-Dimensional Computed Tomography; D006801:Humans; D008175:Lung Neoplasms / Q000000981:diagnostic imaging / Q000532:radiotherapy*; D009068:Movement; D061089:Radiotherapy, Image-Guided / Q000379:methods*; D012119:Respiration; D035501:Uncertainty