title: First clinical results of adaptive radiotherapy based on 3D portal dosimetry for lung cancer patients with atelectasis treated with volumetric-modulated arc therapy (VMAT).
abstract: Atelectasis in lung cancer patients can change rapidly during a treatment course, which may displace the tumor/healthy tissues, or change tissue densities locally. This may result in differences between the planned and the actually delivered dose. With complex delivery techniques treatment verification is essential and inter-fractional adaptation may be necessary. We present the first clinical results of treatment adaptation based on an in-house developed three-dimensional (3D) portal dose measurement (PDM) system.
  
  
  METHODS
  A method was developed for 3D PDM combined with cone beam computed tomography (kV-CBCT) imaging. Lung cancer patients are monitored routinely with this imaging technique. During treatment, the first three fractions are analyzed with 3D PDM and weekly thereafter. The reconstructed measured dose is compared to the planned dose using dose-volume histograms and a γ evaluation. Patients having |γ|> 1 in more than 5% of the (primary tumor or organ at risk) volume were subjected to further analysis. In this study we show the PDM dose changes for five patients.
  
  
  RESULTS
  We detected relevant dose changes induced by changes in atelectasis in the presented cases. Two patients received two treatment adaptations after being detected with PDM confirmed by visual inspection of the kV-CBCTs, and in two other patients the radiation treatment plan was adapted once. In one case no dose delivery change was detected with PDM.
  
  
  CONCLUSIONS
  The first clinical patients show that 3D PDM combined with kV-CBCT is a valuable quality assurance tool for detecting anatomical alterations and their dosimetric consequences during the course of radiotherapy. In our clinic, 3D PDM is fully automated for ease and speed of the procedure, and for minimization of human error. The technique is able to flag patients with suspected dose discrepancies for potential adaptation of the treatment plan.
authors.affiliation: Department of Radiation Oncology (MAASTRO), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre , Maastricht , The Netherlands.
authors.forename: Lucas C G G
authors.initials: LC
authors.lastname: Persoon
authors.forename: Ada G T M
authors.initials: AG
authors.lastname: Egelmeer
authors.forename: Michel C
authors.initials: MC
authors.lastname: Ollers
authors.forename: Sebastiaan M J J G
authors.initials: SM
authors.lastname: Nijsten
authors.forename: Esther G C
authors.initials: EG
authors.lastname: Troost
authors.forename: Frank
authors.initials: F
authors.lastname: Verhaegen
mesh_terms: D000465:Algorithms; D054893:Cone-Beam Computed Tomography; D006801:Humans; D007091:Image Processing, Computer-Assisted; D021621:Imaging, Three-Dimensional; D008175:Lung Neoplasms / Q000532:radiotherapy*; D011379:Prognosis; D001261:Pulmonary Atelectasis / Q000209:etiology / Q000532:radiotherapy*; D011856:Radiographic Image Enhancement; D011874:Radiometry; D061089:Radiotherapy, Image-Guided; D050397:Radiotherapy, Intensity-Modulated / Q000009:adverse effects*