A dosimetric analysis of respiration-gated radiotherapy in patients with stage III lung cancer

BACKGROUND Respiration-gated radiotherapy can permit the irradiation of smaller target volumes. 4DCT scans performed for routine treatment were retrospectively analyzed to establish the benefits of gating in stage III non-small cell lung cancer (NSCLC). MATERIALS AND METHODS Gross tumor volumes (GTVs) were contoured in all 10 respiratory phases of a 4DCT scan in 15 patients with stage III NSCLC. Treatment planning was performed using different planning target volumes (PTVs), namely: (i) PTVroutine, derived from a single GTV plus 'conventional' margins; (ii) PTVall phases incorporating all 3D mobility captured by the 4DCT; (iii) PTVgating, incorporating residual 3D mobility in 3-4 phases at end-expiration. Mixed effect models were constructed in order to estimate the reductions in risk of lung toxicity for the different PTVs. RESULTS Individual GTVs ranged from 41.5 - 235.0 cm3. With patient-specific mobility data (PTVall phases), smaller PTVs were derived than when 'standard' conventional margins were used (p < 0.001). The average residual 3D tumor mobility within the gating window was 4.0 +/- 3.5 mm, which was 5.5 mm less than non-gated tumor mobility (p < 0.001). The reductions in mean lung dose were 9.7% and 4.9%, respectively, for PTVall phases versus PTVroutine, and PTVgating versus PTVall phases. The corresponding reductions in V20 were 9.8% and 7.0%, respectively. Dosimetric gains were smaller for primary tumors of the upper lobe versus other locations (p = 0.02). Respiratory gating also reduced the risks of radiation-induced esophagitis. CONCLUSION Respiration-gated radiotherapy can reduce the risk of pulmonary toxicity but the benefits are particularly evident for tumors of the middle and lower lobes.