title: Evaluation of inter-fraction and intra-fraction errors during volumetric modulated arc therapy in nasopharyngeal carcinoma patients.
abstract: BACKGROUND
  This prospective study was conducted to evaluate inter- and intra-fraction errors in nasopharyngeal carcinoma (NPC) patients undergoing volumetric modulated arc therapy (VMAT) using cone-beam computed tomography (CBCT) and to thus obtain planning target volume (PTV) margins to effectively guide treatment in the future.
  
  
  METHODS
  Fifteen NPC patients scheduled to undergo VMAT were prospectively enrolled in the study. For each patient, three CBCT scans were obtained; one after daily conventional positioning, one after online correction with 2 mm tolerance and one after 1 week of VMAT delivery. The scans were registered to the planning CT to determine the inter- and intra-fraction errors. Patient positioning errors were analyzed for time trends over the course of radiotherapy. PTV margins were calculated from the systematic (Σ) and random (σ) errors.
  
  
  RESULTS
  The average absolute values of the pre-correction, post-correction and intra-fraction errors (in order) were 1.1, 0.6 and 0.4 mm in the medial-lateral (ML) direction, 1.2, 0.7 and 0.5 mm in the superior-inferior (SI) direction and 1.1, 0.7 and 0.5 mm in the anterior-posterior (AP) direction. The corresponding Σ were 1.0-1.4 mm, 0.4-0.5 mm and 0.2-0.4 mm, while the corresponding σ were 0.7-0.8 mm, 0.6-0.7 mm and 0.5-0.6 mm. With time, gradual increases in both the inter- and intra-fraction three-dimensional displacements were observed (P = 0.019 and P = 0.044, respectively). The total PTV margins accounting for pre-correction and intra-fraction errors were 3.4-4.1 mm and those accounting for post-correction and intra-fraction errors were 1.7-2.2 mm.
  
  
  CONCLUSIONS
  CBCT is an effective modality to evaluate and improve the accuracy of VMAT in NPC patients. Inter- and intra-fraction three-dimensional displacements increased as a function of time during the course of radiotherapy. In our institution, we recommend a PTV margin of 5 mm for NPC patients undergoing VMAT without CBCT and 3 mm for those treated with rigorous daily CBCT scans.
authors.affiliation: State Key Laboratory of Oncology in Southern China, Department of Radiation Oncology, Cancer Center, Sun Yat-sen University, Guangzhou 510060, PR China.
authors.forename: Wen-Jing
authors.initials: WJ
authors.lastname: Yin
authors.forename: Ying
authors.initials: Y
authors.lastname: Sun
authors.forename: Feng
authors.initials: F
authors.lastname: Chi
authors.forename: Jian-Lan
authors.initials: JL
authors.lastname: Fang
authors.forename: Rui
authors.initials: R
authors.lastname: Guo
authors.forename: Xiao-Li
authors.initials: XL
authors.lastname: Yu
authors.forename: Yan-Ping
authors.initials: YP
authors.lastname: Mao
authors.forename: Zhen-Yu
authors.initials: ZY
authors.lastname: Qi
authors.forename: Ying
authors.initials: Y
authors.lastname: Guo
authors.forename: Meng-Zhong
authors.initials: MZ
authors.lastname: Liu
authors.forename: Jun
authors.initials: J
authors.lastname: Ma
mesh_terms: D000328:Adult; D000368:Aged; D002277:Carcinoma; D054893:Cone-Beam Computed Tomography / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D000077274:Nasopharyngeal Carcinoma; D009303:Nasopharyngeal Neoplasms / Q000532:radiotherapy*; D011880:Radiotherapy Planning, Computer-Assisted / Q000379:methods*; D061089:Radiotherapy, Image-Guided / Q000379:methods*; D050397:Radiotherapy, Intensity-Modulated / Q000379:methods*
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