title: Four-dimensional dose distributions of step-and-shoot IMRT delivered with real-time tumor tracking for patients with irregular breathing: constant dose rate vs dose rate regulation.
abstract: OBJECTIVE
  Dose-rate-regulated tracking (DRRT) is a tumor tracking strategy that programs the MLC to track the tumor under regular breathing and adapts to breathing irregularities during delivery using dose rate regulation. Constant-dose-rate tracking (CDRT) is a strategy that dynamically repositions the beam to account for intrafractional 3D target motion according to real-time information of target location obtained from an independent position monitoring system. The purpose of this study is to illustrate the differences in the effectiveness and delivery accuracy between these two tracking methods in the presence of breathing irregularities.
  
  
  METHODS
  Step-and-shoot IMRT plans optimized at a reference phase were extended to remaining phases to generate 10-phased 4D-IMRT plans using segment aperture morphing (SAM) algorithm, where both tumor displacement and deformation were considered. A SAM-based 4D plan has been demonstrated to provide better plan quality than plans not considering target deformation. However, delivering such a plan requires preprogramming of the MLC aperture sequence. Deliveries of the 4D plans using DRRT and CDRT tracking approaches were simulated assuming the breathing period is either shorter or longer than the planning day, for 4 IMRT cases: two lung and two pancreatic cases with maximum GTV centroid motion greater than 1 cm were selected. In DRRT, dose rate was regulated to speed up or slow down delivery as needed such that each planned segment is delivered at the planned breathing phase. In CDRT, MLC is separately controlled to follow the tumor motion, but dose rate was kept constant. In addition to breathing period change, effect of breathing amplitude variation on target and critical tissue dose distribution is also evaluated.
  
  
  RESULTS
  Delivery of preprogrammed 4D plans by the CDRT method resulted in an average of 5% increase in target dose and noticeable increase in organs at risk (OAR) dose when patient breathing is either 10% faster or slower than the planning day. In contrast, DRRT method showed less than 1% reduction in target dose and no noticeable change in OAR dose under the same breathing period irregularities. When ±20% variation of target motion amplitude was present as breathing irregularity, the two delivery methods show compatible plan quality if the dose distribution of CDRT delivery is renormalized.
  
  
  CONCLUSIONS
  Delivery of 4D-IMRT treatment plans, stemmed from 3D step-and-shoot IMRT and preprogrammed using SAM algorithm, is simulated for two dynamic MLC-based real-time tumor tracking strategies: with and without dose-rate regulation. Comparison of cumulative dose distribution indicates that the preprogrammed 4D plan is more accurately and efficiently conformed using the DRRT strategy, as it compensates the interplay between patient breathing irregularity and tracking delivery without compromising the segment-weight modulation.
authors.affiliation: Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
authors.forename: Xiaocheng
authors.initials: X
authors.lastname: Yang
authors.forename: Sarah
authors.initials: S
authors.lastname: Han-Oh
authors.forename: Minzhi
authors.initials: M
authors.lastname: Gui
authors.forename: Ying
authors.initials: Y
authors.lastname: Niu
authors.forename: Cedric X
authors.initials: CX
authors.lastname: Yu
authors.forename: Byong Yong
authors.initials: BY
authors.lastname: Yi
mesh_terms: D006801:Humans; D008175:Lung Neoplasms / Q000503:physiopathology / Q000532:radiotherapy; D058958:Organs at Risk / Q000528:radiation effects; D010190:Pancreatic Neoplasms / Q000503:physiopathology / Q000532:radiotherapy; D011829:Radiation Dosage; D011879:Radiotherapy Dosage; D011880:Radiotherapy Planning, Computer-Assisted / Q000379:methods*; D050397:Radiotherapy, Intensity-Modulated / Q000009:adverse effects / Q000379:methods*; D015203:Reproducibility of Results; D012119:Respiration; D013997:Time Factors