Inter-fraction Organ Motion

Management and Observation

Adam Schwartz- Milwaukee, WI.

UW-Lacrosse Medical Dosimetry
5/1/2018
 Organ/Tumor Motion
• The geometrical location of a tumor may be altered at
points of the respiratory cycle
https://www.youtube.com/watch?v=nZ044EicYO41
• Most commonly an issue in tumors of the abdomen and
lungs
• Considerations must be made in order to deliver the
maximum radiation dose to the tumor while sparing
normal tissues
 4-D Computed Tomography
• Static CT will show distortions in tumor position, shape,
and size2
• 4D CT assembled using 3D CT scans taken throughout
the entirety of the respiratory cycle
– 4th dimension refers to time
• Images are tagged with respiratory signals and sorted,
creating CT data sets that correspond to a phase of the
respiratory cycle
• Together, they create a CT data bank with information
relevant to the entire breathing cycle2
 4-D Computed Tomography
• Home position of the tumor and the locomotion it incurs
can be accurately mapped
• Information allows tumor location to be predicted and
more accurate treatment plan can then be developed

A representation of 4D CT workflow. Image courtesy of AAPM Report 913.

 Respiratory Gating
• Software allows the definition of a physical window, only
delivering treatment as the tumor passes within these
extents4
• External radiotherapy synchronized with the
respiration-gating signal was developed three decades
ago5
• Benefits
– Spare dose to healthy tissues
– Deliver higher and more precise doses, allowing for
the shortening of a treatment plan
 Fiducial Markers
• Imbedded at the tumor site, normally gold
• Surrogate to observing patient anatomy
• Can indicate tumor motion, rotations, and deformation
during the respiratory cycle

A lung tumor implanted with 4 gold fiducial markers. Image

courtesy of AAPM Report 913
 Deep Inspiration Breath Hold (DIBH)
• A deep breath is taken and held while a fractional dose is
given
• Hold breath for up to 20 seconds
• Radiation beam will only turn on during appropriate
breath hold
– Moves the heart away from the chest6

DIBH helps to pull critical structures away from the

treatment volume.6
 Deep Inspiration Breath Hold (DIBH)
• Applicable to treatments of:
– Left sided breast cancer
– Lymphoma in the chest region
– Other tumors of the chest or abdomen as required
• Assessed on an individual basis:
– Ability to maintain a breath hold
– Patient anatomy
 Active Breathing Control (ABC)
• Automated gating intended to achieve reproducible
breath holds
• A compressor apparatus suspends patient breathing at
a predetermined position7
– Often moderate or deep inhale
• Patient can release a pressure switch at any time

https://www.elekta.com/dam/jcr:1afb7290-dec0-477b-9ebc-ac130ea8fa48/Active-
Breathing-Coordinator-brochure-Respiratory-motion-management.pdf
 Active Breathing Control (ABC)
• Mechanism:
– Patient nose clamped and
breathing tube placed in mouth
– Digital spirometer measures
respiratory trace and is
connected to a balloon valve.
– A valve in breathing tube closes
at predefined point so no more
air can be breathed in, stopping A patient using an ABC apparatus8
any movement7
 Conclusion
• Respiratory motion causes tumor movement in cases of
the abdomen and chest
• Respiratory motion management alleviates geometrical
errors caused by tumor motion
• Planning optimized as dose to the target volume is
increased and OAR dose is decreased
• Many interventions available and chosen to best suit the
individual patient and disease
 References
1. uihealthcare. Moving lung tumor during imaging (radiation therapy). YouTube.
https://www.youtube.com/watch?v=nZ044EicYO4. Published June 19, 2013. Accessed May 1, 2018.
2. Jiang SB. An Brief Introduction to 4D CT Scanning. An Brief Introduction to 4D CT Scanning. Accessed
April 29, 2018.
3. Keall PJ, Mageras GS, Balter JM, et al. The management of respiratory motion in radiation oncology report
of AAPM Task Group 76a). American Association of Physicists in Medicine. July 2006.
doi:10.1118/1.2349696.
4. Respiratory gating. Stanford Health Care (SHC) - Stanford Medical Center.
https://stanfordhealthcare.org/medical-treatments/r/radiation-therapy/radiation-therapy-types/respiratory-
gating.html. Accessed May 1, 2018.
5. Ohara K, Okumura T, Akisada M, et al. Irradiation synchronized with respiration gate. Int J Radiat Oncol
Biol Phys. 1989;17:853–7.
6. Deep inspiration breath hold (DIBH). Peter MacCallum Cancer Centre.
https://www.petermac.org/services/treatment/radiation-therapy/other-advanced-technologies/deep-
inspiration-breath-hold-dibh. Published September 16, 2016. Accessed May 1, 2018.
7. Active Breathing Coordinator. Swedish. https://www.swedish.org/services/cancer-institute/our-
services/radiation-therapy/types-of-radiation-therapy/active-breathing-coordinator. Accessed May 2, 2018.
8. Elekta. Active Breathing Coordinator™. Elekta AB. https://www.elekta.com/radiotherapy/treatment-
solutions/motion-management/active-breathing-coordinator.html. Accessed May 2, 2018.