Tumor trailing strategy for intensity-modulated radiation therapy of moving targets

Internal organ motion during the course of radiation therapy of cancer affects the distribution of the delivered dose and, generally, reduces its conformality to the targeted volume. Previously proposed approaches aimed at mitigating the effect of internal motion in intensity-modulated radiation therapy (IMRT) included expansion of the target margins, motion-correlated delivery (e.g., respiratory gating, tumor tracking), and adaptive treatment plan optimization employing a probabilistic description of motion. We describe and test the tumor trailing strategy, which utilizes the synergy of motion-adaptive treatment planning and delivery methods. We regard the (rigid) target motion as a superposition of a relatively fast cyclic component (e.g., respiratory) and slow aperiodic trends (e.g., the drift of exhalation baseline). In the trailing approach, these two components of motion are decoupled and dealt with separately. Real-time motion monitoring is employed to identify the "slow" shifts, which are then corrected by applying setup adjustments. The delivery does not track the target position exactly, but trails the systematic trend due to the delay between the time a shift occurs, is reliably detected, and, subsequently, corrected. The "fast" cyclic motion is accounted for with a robust motion-adaptive treatment planning, which allows for variability in motion parameters (e.g., mean and extrema of the tidal volume, variable period of respiration, and expiratory duration). Motion-surrogate data from gated IMRT treatments were used to provide probability distribution data for motion-adaptive planning and to test algorithms that identified systematic trends in the character of motion. Sample IMRT fields were delivered on a clinical linear accelerator to a programmable moving phantom. Dose measurements were performed with a commercial two-dimensional ion-chamber array. The results indicate that by reducing intrafractional motion variability, the trailing strategy enhances relevance and applicability of motion-adaptive planning methods, and improves conformality of the delivered dose to the target in the presence of irregular motion. Trailing strategy can be applied to respiratory-gated treatments, in which the correction for the slow motion can increase the duty cycle, while robust probabilistic planning can improve management of the residual motion within the gate window. Similarly, trailing may improve the dose conformality in treatment of patients who exhibit detectable target motion of low amplitude, which is considered insufficient to provide a clinical indication for the use of respiratory-gated treatment (e.g., peak-to-peak motion of less than 10 mm). The mechanical limitations of implementing tumor trailing are less rigorous than those of real-time tracking, and the same technology could be used for both.