The use of gated and 4D CT imaging in planning for stereotactic body radiation therapy.

The localization of treatment targets is of utmost importance for patients receiving stereotactic body radiation therapy (SBRT), where the dose per fraction is large. While both setup or respiration-induced motion components affect the localization of the treatment volume, the purpose of this work is to describe our management of the intrafraction localization uncertainty induced by normal respiration. At our institution, we have implemented gated computed tomography (CT) acquisition with an active breathing control system (ABC), and 4-dimensional (4D) CT using a skin-based marker and retrospective respiration phase-based image sorting. During gated simulation, 3D CT images were acquired corresponding to end-inhalation and end-exhalation. For 4D CT imaging, 3D CT images were acquired corresponding to 8 phases of the respiratory cycle. In addition to gated or 4D CT images, we acquired a conventional free-breathing CT (FB). For both gated and 4D CT images, the target contours were registered to the FB scan in the planning system. These contours were then combined in the FB image set to form the internal target volume (ITV). Dynamic conformal arc treatment plans were generated for the ITV using the FB scan and the gated or 4D scans with an additional 7-mm margin for patient setup uncertainty. We have described our results for a pancreas and a lung tumor case. Plans were normalized so that the PTV received 95% of the prescription dose. The dose distribution for all the critical structures in the pancreas and lung tumor cases resulted in increased sparing when the ITV was defined using gated or 4D CT images than when the FB scan was used. Our results show that patient-specific target definition using gated or 4D CT scans lead to improved normal tissue sparing.