AJ Kressin Conformal Terminology Breathing Movement and Respiratory Gating The natural act of breathing has consequences when

it comes to trying to deliver accurate external beam radiation therapy to a site within the human body. With each breath taken, there is motion of internal organs and anatomical structures. This means there is also movement of the tumor if it lies within or on the surface of these moving structures. If the tumor is moving during radiation treatment, additional margins may be added to the target volume in the treatment plan in order to take into account this movement or the breathing cycle may be monitored and the linear accelerator will only beam on during certain intervals of the breathing cycle.1,2 However, adding additional margin to the clinical target volume (CTV) results in more normal tissue being treated. Increased radiation to normal healthy tissues near the target volume results in greater toxicities to these tissues.2 A more accurate delivery of radiation is possible with the use of respiratory gating in cases where the tumor is located on or within organs or structures that are susceptible to movement with each breath taken by the patient. In respiratory gating, a camera monitors the patients breathing by syncing to a small box placed on the patients upper abdomen and displaying the movements of the gating box as a 2-dimensional graph on a computer screen. Desired portions of the breathing cycle can then be selected and the treatment machine will only beam on during the requested portion of the breathing cycling. During simulation, images taken during the selected portions of the breathing cycle can be binned. This allows for treatment planning to be done on only the selected images. Tumors located in the abdominal cavity and in the thoracic cavity generally use different types of gating. When treating tumors located in the abdominal cavity, respiratory gating is typically used to deliver radiation on the exhale, whereas tumors in the thoracic cavity are treated on the inhale portion of the breathing cycle. It is easy to forget which locations use each type of respiratory gating. I dont have any real quick and easy ways to remember which type of gating is used in the different locations, but if you stop to think about it logically it will only take a few seconds for you to remember. Here is the thought process that I generally go through to remind myself. When dealing with tumors in the thoracic cavity, especially those on the left side of the body, the goal is to eliminate as much radiation to the heart as possible. This means that when we are treating a tumor in the lungs, chest wall or breast we want to treat when the tumor is further away from the heart. Logically speaking, that means we want to treat on inhale because that is when the tumor is at an increased distance from the heart due to expansion of the lungs and chest wall. This is different than when we are trying to treat a tumor in the abdominal cavity (usually upper abdominal cavity). When treating tumors in the abdominal region, we are trying to be as precise as possible to avoid unnecessary irradiation of critical structures and normal tissues. Therefore, we want to treat on exhale instead of inhale. This makes sense because there are great variations or differences from inhale to inhale, especially in a patient who is stressed or nervous during treatment. However, no matter how great or small each inhale is the patient will always return to the same point during each exhale. You may also think about this in terms of breathing when someone is exercising. When they first start out, their breaths are slow, deep and methodical. As they get further into the workout, their breaths become shallower and more rapid. No matter how fast or slow or deep or shallow that persons inhales become, they will always exhale to the same point. That is why

treatments are delivered more accurately on exhales. Greater accuracy results in greater dose to the target volume and less dose or toxicity to normal tissues. Helpful resources: How respiratory gating is carried out http://www.youtube.com/watch?v=xgrfK2UR0c8 (I apologize if the sound stops working halfway through the video. However, I still found the illustrations to be very helpful visualizations.) Additional visualization of using gating to regulate when beam is on: http://www.youtube.com/watch?v=lh5aH_vwOC0 Here is an article that does a good of explaining the implications of breathing-induced organ motion and the importance of respiratory gating for some specific tumor locations: Ramsey CR, Scaperoth D, Arwood D, and Oliver AL. Clinical efficacy of respiratory gated conformal radiation therapy. Med Dos. 1999;24(2):115-119.

References 1. Yue NJ, Goyal S, Kim LH, AMusD, Khan A, and Haffty BG. Patterns of intrafractional motion and uncertainties of treatment setup reference systems in accelerated partial breast irradiation for right- and left-sided breast cancer. Practical Radiat Oncol. 2014;4(1):6-12. http://dx.doi.org/10.1016/j.prro.2012.12.003 2. Germain F, Beaulieu L, and Fortin A. Individualized margins in 3D conformal radiotherapy planning for lung cancer: analysis of physiological movements and their domsimetric impacts. Med Dos. 2008;33(1):48-54. http://dx.doi.org/10.1016/j.meddos.2007.05.003