The impact of breathing motion versus heterogeneity effects in lung cancer treatment planning.

The purpose of this study is to investigate the effects of tissue heterogeneity and breathing-induced motion/deformation on conformal treatment planning for pulmonary tumors and to compare the magnitude and the clinical importance of changes induced by these effects. Treatment planning scans were acquired at normal exhale/inhale breathing states for fifteen patients. The internal target volume (ITV) was defined as the union of exhale and inhale gross tumor volumes uniformly expanded by 5 mm. Anterior/posterior opposed beams (AP/PA) and three-dimensional (3D)-conformal plans were designed using the unit-density exhale ("static") dataset. These plans were further used to calculate (a) density-corrected ("heterogeneous") static dose and (b) heterogeneous cumulative dose, including breathing deformations. The DPM Monte Carlo code was used for dose computations. For larger than coin-sized tumors, relative to unit-density plans, tumor and lung doses increased in the heterogeneity-corrected plans. In comparing cumulative and static plans, larger normal tissue complication probability changes were observed for tumors with larger motion amplitudes and uncompensated breathing-induced hot/cold spots in lung. Accounting for tissue heterogeneity resulted in average increases of 9% and 7% in mean lung dose (MLD) for the 6 MV and 15 MV photon beams, respectively. Breathing-induced effects resulted in approximately 1% and 2% average decreases in MLD from the static value, for the 6 and 15 MV photon beams, respectively. The magnitude of these effects was not found to correlate with the treatment plan technique, i.e., AP/PA versus 3D-CRT. Given a properly designed ITV, tissue heterogeneity effects are likely to have a larger clinical significance on tumor and normal lung treatment evaluation metrics than four-dimensional respiratory-induced changes.