Liver motion during cone beam computed tomography guided stereotactic body radiation therapy

Understanding motion characteristics of liver such as, interfractional and intrafractional motion variability, difference in motion within different locations in the organ, and their complex relationship with the breathing cycles are particularly important for image-guided liver SBRT. The purpose of this study was to investigate such motion characteristics based on fiducial markers tracked with the x-ray projections of the CBCT scans, taken immediately prior to the treatments.

Twenty liver SBRT patients were analyzed. Each patient had three fiducial markers (2 × 5-mm gold) percutaneously implanted around the gross tumor. The prescription ranged from 2 to 8 fractions per patient. The CBCT projections data for each fraction (∼650 projections∕scan), for each patient, were analyzed and the 2D positions of the markers were extracted using an in-house algorithm. In total, >55 000 x-ray projections were analyzed from 85 CBCT scans. From the 2D extracted positions, a 3D motion trajectory of the markers was constructed, from each CBCT scans, resulting in left-right (LR), anterior-posterior (AP), and cranio-caudal (CC) location information of the markers with >55 000 data points. The authors then analyzed the interfraction and intrafraction liver motion variability, within different locations in the organ, and as a function of the breathing cycle. The authors also compared the motion characteristics against the planning 4DCT and the RPM™ (Varian Medical Systems, Palo Alto, CA) breathing traces. Variations in the appropriate gating window (defined as the percent of the maximum range at which 50% of the marker positions are contained), between fractions were calculated as well.

The range of motion for the 20 patients were 3.0 ± 2.0 mm, 5.1 ± 3.1 mm, and 17.9 ± 5.1 mm in the planning 4DCT, and 2.8 ± 1.6 mm, 5.3 ± 3.1 mm, and 16.5 ± 5.7 mm in the treatment CBCT, for LR, AP, and CC directions, respectively. The range of respiratory period was 3.9 ± 0.7 and 4.2 ± 0.8 s during the 4DCT simulation and the CBCT scans, respectively. The authors found that breathing-induced AP and CC motions are highly correlated. That is, all markers moved cranially also moved posteriorly and vice versa, irrespective of the location. The LR motion had a more variable relationship with the AP∕CC motions, and appeared random with respect to the location. That is, when the markers moved toward cranial-posterior direction, 58% of the markers moved to the patient-right, 22% of the markers moved to the patient-left, and 20% of the markers had minimal∕none motion. The absolute difference in the motion magnitude between the markers, in different locations within the liver, had a positive correlation with the absolute distance between the markers (R(2) = 0.69, linear-fit). The interfractional gating window varied significantly for some patients, with the largest having 29.4%-56.4% range between fractions.

This study analyzed the liver motion characteristics of 20 patients undergoing SBRT. A large variation in motion was observed, interfractionally and intrafractionally, and that as the distance between the markers increased, the difference in the absolute range of motion also increased. This suggests that marker(s) in closest proximity to the target be used.