MOTION

MANAGEMENT IN
EXTERNAL BEAM
RADIOTHERAPY
MODERATOR
DR.RENU MADAN
 GOALS OF RADIOTHERAPY
Maximal tumour control,
achievable by increasing NTCP
the tumour dose TCP
Minimal normal tissue
toxicity, achievable by
minimizing the doses to the
normal tissue

probability
• Depicted as the therapeutic
index
• Increasing the gap between
the two curves – prerequisite
for improving the therapeutic
index
Dose
IN MOTION
MANAGEMENT STRATEGY
WE INCREASE THE
THERAPUTIC INDEX BY
DECREASING THE
NORMAL TISSUE
TOLERANCE
MOTION MANAGEMENT ???
THERAPUTIC INDEX ___ THE VOLUME
EFFECT
*For example, lets
consider a 3 cm tumor
(ORANGE) with a 1 cm
safety margin for
irradiation (PEEL)
*The volume of ORANGE
WITH PEEL, is # 66 cc
If the safety margin could
be reduced to 0.5 cm
with precision and image
guidance, the volume of
the ORANGE is # 33 cc…!!
*dose delivered
can be
doubled…!!
INTRODUCTION
• Tumor motion IS
• Complex – individual for every patient
• Depends on tumour location
• MC in superoinferior direction

Tumor

Cross-sectional View
of Patient’s Chest Tumor

Some motion is mostly Some motion is mostly All tumor motion is

Anterior / Posterior Superior / Inferior Complex
(most common)
MOTION_TYPES

ORGAN MOTION TYPES TYPES OF MOVEMENT

• Inter fraction motion • TRANSLATIONAL

• Intra fraction motion *Cranio caudal
*lateral
*vertical
• ROTATIONAL
*Roll
*Pitch
*Yaw
• SHAPE
*flattening
*ballooning
*Pulsation
 INTRAFRACTION MOTION
 Lung:  Liver:
 Quiet breathing  Normal Breathing: 10 – 25 mm
 AP 2.4 ± 1.3 mm  Deep breathing: 37 – 55 mm
 Lateral 2.4 ± 1.4 mm  Kidney:
 SI 3.9 ± 2.6 mm  Normal breathing: 11 -18 mm
 Deep Breathing: 14 -40 mm
 2° to Cardiac motion: 9 ± 6
mm lateral motion
 Pancreas:
 Average 10 -30 mm
 Tumors located close to the
chest wall and in upper lobe
show reduced interfraction
motion.

 Maximum motion is in
tumors close to mediastinum
 INTERFRACTION MOTION
• PROSTATE • RECTUM
• Motion max in SI & AP • Dia: 3 – 46 mm
• SI 1.7 – 4.5mm • Volume 20% - 40%
• AP 1.5 – 4.1mm • BLADDER
• Lateral 0.7 – 1.9 mm • Max transverse diameter mean
• SV motion > prostate 15 mm variation
• UTERUS • SI displacement 15mm
• SI:7mm • Volume variation 20% - 50%.
• AP:4mm
• CERVIX
• SI: 4mm
PROBLEMS

 Internal organ & tumor movement

 Risk of missing the target

 Increased dose to the surrounding critical structures

 Uncontrolled breathing mobility of tumors .

PROBLEMS

• Artefacts during image acquisition – size & shape of

the tumour can be significantly distorted
• Treatment planning limitations

Tumor

Free Breathing scan Motion adjusted scanning

PROBLEMS _ ERRORS
 Random
errors

External Internal
random random
errors errors

 Daily positioning variations

Internal Organ Motion
 Discrepancy in day to
matching of laser to
skin markings
 Physical changes leading to altered
Skin markings
IN ORDER TO OVERCOME

• FIXED PROTOCOLS
• PROPER KNOWLEDGE DURING PLANNING CT
• ACCURATE ASSESMENT OF MOTION __ 4D CT AND
ACTIVE IMAGING
• SOPHESTICATED MOTION COMPENSATION
STRATEGIES
RESPIRATORY GATING
TRACKING etc.
Assuming that the appropriate infrastructure is in place
,steps in addressing the tumor motion SPECIFICALLY are
• CHARACTERIZING the tumor motion
• SELECTING AND IMPLEMENTING a motion management strategy
• VERIFYING accurate radiotherapy delivery using image guidance at
treatment.
What Is Motion Management??
“Techniques and technologies employed to manage
the tumour motion during simulation and
treatment, so as to decrease the risk of missing the
target and irradiating the normal tissue”

Intra-fraction management is
especially important with
techniques like SBRT (long
treatment times)
TYPES OF RESPIRATORY MOTION
MANAGEMENT METHODS

• SLOW CT scan
• Breath hold scan
• 4D CT scan
• Gating
• Tracking
 Slow CT scan

• CT is operated very slowly and the couch stays in a particular

position longer than the duration of one breathing cycle.
Time per revolution – 4 seconds
Advantages:
• Delineation on slow CT images have been shown to be more
reproducible, and equivalent to doing multiple fast scans for
encompassing motion if a 5mm margin is added to the slow
scan
•Disadvantages:
• Loss of resolution ,motion blurring, larger
errors in tumor and normal organ
delineation
• Respiration changes between imaging and
treatment; requiring additional margins
Combined Inhale & Exhale CT
• Both end inhalation and end exhalation CT scans are
obtained
• volumes contoured in both the sets of images and then
they are fused.
Advantage over slow CT scan:
• Blurring caused by the motion present during free
breathing is significantly reduced.
Disadvantage:
• Relies on the patient’s ability to hold his or her breath
reproducibly.
Breath hold scan
Freezing the tumor motion by a voluntary or forced breath
hold while the radiation beam is on.

Reproducibility of the breath hold needs to be guaranteed

 Patient cooperation and comfort should be of utmost
importance when one is selecting this technique

Usually combined with some means of monitoring the

breath hold, ranging from spirometry to surface motion
tracking with feedback to ensure reproducibility
Deep Inspiration… Breath Hold (DIBH)

• Deep inspiration breath hold (DIBH) :- Free-breathing

interval followed by a breath hold at approximately
100% vital capacity.
• The patient is trained to take a deep breath and exhale
slowly and then to take another deep breath and hold
it for as long as he/she can.
NORMAL BREATHING DEEP INSPIRATION BREATH HOLD DEEP EXPIRATION
Disadvantages:

• Patient compliance

• Lung cancer patients may have a more difficult time holding

their breath because of their associated compromised
pulmonary status.
 Forced Breath Hold (ABC)
• Assisting device for improving
the reproducibility of the
breath hold.
• Active breathing coordinator
(Elekta)
• The patient is verbally coached
to help achieve steady
breathing.
• Safety valve, controlled by the
patient.
• Breathing can be suspended at
any predetermined position.
• Treatments at moderate DIBH,
which consist of holding the
breath at approximately 75% of
the vital capacity, have been
shown to achieve good
reproducibility, while being
comfortable to the patient.
 Shallow Breathing With
Immobilisation- Dampening
• One of the easiest ways of minimizing
organ motion in the upper abdomen and
thorax is to use abdominal compression.

• Utilizes a stereotactic body frame with an

attached plate that compresses the
abdomen reduces the diaphragmatic
excursions, permitting limited shallow
respiration. Also acts as a reference system.

• A rigid arc and a scaled screw that connect

the plate with the frame help in achieving
reproducibility.
 4D-CT / Respiration-correlated CT

• Determines the mean tumor position & tumor range

of motion for treatment planning
• Can be used to reconstruct all phases of respiration
• The MIP tool can be used for obtaining the tumor-
motion-encompassing target volume
 4-D Imaging
Train the patient to breath regularly

Setup/immobilize the patient in the treatment position

Place bellows / infra-red marker over the diaphragm

Acquire the images at different phases or at a particular phase (prospective

scanning)

System sorts the images into different 3D image sets with the help of
respiratory signal
(either sinogram or image sorting, sinogram sorting reduces artifacts)
4D CT Scan-RPM System
INFRA RED CAMERA

PLASTIC MARKER
WITH INFRA RED
REFLECTORS
IR CAMERA_ CALIBRATION
NO SYNC _ _ WRONG POSITION
video
The images are obtained by prospective triggering or
retrospective triggering
•
Prospective triggering: the scans are acquired only during a
specified phase of respiration – a single set of CT scans is
acquired.
•
Retrospective triggering: images are continuously acquired
in all the phases of the respiratory cycle for each position
and subsequently the images are sorted out into various
respiratory cycle phases
Prospective CT Image Acquisition

Inhalation

Exhalation

Scan Scan Scan

CT Scan
Axial scan trigger, Axial scan trigger, Axial scan trigger,
1st couch position 2nd couch position 3rd couch position
Retrospective 4D CT Image Acquisition

Inhalation

Exhalation
“Image acquired”
signal to RPM
system

X-ray on
1st couch 2nd couch 3rd couch
position position position

(Ford 2003, Vedam 2003)

• Images acquired are registered using a Deformable image
registration algorithm process of obtaining & applying a
coordinate transformation between two or more data sets

• Using the gating work station, the 4D CT images are sorted out
into various breathing phases based on the breathing signals 
an interval of breathing, (eg., between 30% and 70%) is defined
as a gating window

• Target and OAR delineation is done on one reference system,

and is applied to the gating window phase
DISADVANTAGES

• In pts who are regular breathers the quality of 4D scans can be

very good BUT

• In pts with irregular breathing ,there may be artefacts apparent

at the junctions between adjustable table positions

• If these occur in areas of tumor ,they may introduce potential

errors in the contouring.

• One must be able to take this into account.

• 4D CT captures motion only during breathing cycles it has sampled ,
although it is often displayed as a time loop giving the semblance of
continuous breathing

• The captured range of motion may or may not be same during

treatment

• So its confirmation at the time of treatment is critically important.

STRATEGIES TO IMPROVE QUALITY OF
4D CT SCANS
• LUNG DISEASE _ regular breathing problem
• VIEDO PROMPT
• AUDIO VISUAL BIO FEED BACK
AUDIO VISUAL FEEDBACK
 MIP – MAXIMUM INTENSITY PROJECTION

For each pixel in an image, the software assigns a

maximum brightness value it has ever achieved during
the scan
So if the tumour has been within the ray projection at
anytime during the breathing cycle, it will show a
projection of the tumour with maximum brightness there
Choice of image set in a 4Dct
• Minimum intensity projection

• Used for organs where the surrounding tissues is more dense than
the tumor liver
CORRECTNESS OF MOTION ENVELOP TARGET
DEFINITIONS_4D CT

• OVERESTIMATES???__ DEBATE

• Some times it overestimates the presence of tumor at the extreme positions

------->>

• Because it does not take into account that tumor spends unequal durations
at different portions of its trajectory

• So it is better to weigh the portion in which the tumor spends the most time

• Some times it UNDERESTIMATES the full extent of potential motion during

treatment
Motion-PDF Based Dosimetric Optimisation
• Motion of the tumor can be determined via 4D CT and a PDF
(PROBABILITY DENSITY FUNCTION) of the tumor motion can
then be derived
• Based on the probability of the tumor being within a
particular voxel, the dose to that particular voxel is adjusted
 by irradiating the regions that are always occupied by
the tumor with a higher dose (eg., mid-respiration position)
compared to those regions with relatively lesser probability
of having the tumour at all the phases (eg., the end-
expiratory and end-inspiratory).
CONTOURING GUIDE LINES

•ICRU 50 AND ICRU 62

POPULATION BASED MARGINS

• Adding population-based
margins has been the standard
clinical practice for many years.
• International Commission on PTV GTV
Radiation Units and
CTV
Measurements (ICRU) Report
50.
ICRU 62
• ITV: internal margin around the
CTV, to account for the tumor
motion PTV GTV
• Population based average CTV
calculated depending on the site
ITV
• Only valid for the “average” patient.
• In patients where the target motion is larger than the population
average, the target will be under-dosed.
• In patients where the target motion is smaller than the population
average, the surrounding normal tissues will be overdosed.
• NOT SPECIFIC
PATIENT SPECIFIC MARGINS

• If information on the tumor motion in a patient is available, an

internal margin which is often asymmetric, can be designed on a
patient-by-patient basis according to these measurements.
• Because the ITV includes motion, it cannot be detected with a single
static image of the patient.
• It must be determined with imaging techniques that show the entire
range of tumor motion, like
FLUROSCOPY
SLOW CT SCAN
4-D CT SCAN
COMBINED INHALE & EXHALE CT SCAN
SETUP AND TREATMENT DELIVERY

• Patients are placed on the treatment couch, immobilized, and

aligned, based on simulation position
• Setup verification should be performed with
• Orthogonal kV or MV films - based on bony alignment
• CT imaging (either CT-on-Rails or cone-beam CT) - for both tumor and
normal anatomy visualization
GATING

Deriving the
tumour position
External gating from external
breathing signals
Eg: RPM
Respiratory Imaging system
gating monitors the
motion of
implanted fiducial
Internal gating
Eg: RTRT by
Mistibishi &
Hokkadio
university
 GATING

“Motion management technique where radiation is delivered only during a

portion of the breathing cycle, when the tumor is in the path of the beam”
• With knowledge of the breathing cycle signal, the beam can be triggered
during the desired portion of the breathing cycle
• 4D CT scan is a prerequisite for gating
• Patient is given video goggles that present a wave form of his
breathing,

• Is trained such that a closed feed back loop allows the patient to
control his breathing by keeping the waveform between the two
lines visible on the goggles constant end-inspiratory & end-
expiratory positions can be maintained

• Using the RPM system (real time position management) the

abdominal wall movements are tracked using an IR camera and
an external marker block
Images are transferred to the treatment planning system

GTV contoured on the appropriate window

ITV generated using GTV from all the phases within the gating
window
OR
MIP(maximum intensity projection) generated using post
processing software

Uniform expansion given, to generate PTV

OARs delineated

Planning, evaluation, quality assurance

Patient is re-coached before treatment delivery

Verification done by using KV CBCT under controlled free breathing

Corresponding shifts calculated and corrected.

Fluroscopy used for set up verification and gating verification

Gated treatment delivered using RPM beam is ON only when the

PTV comes within the gating window
 tumor-tracking methods
• Repositioning of the radiation beam dynamically so as to follow
the tumor’s changing position
• eliminate the need for a tumor-motion margin in the dose
distribution
• Four steps
• Identify the tumor position in real time
• anticipate the tumor motion to allow for time delays in the response of the beam-
positioning system
• reposition the beam
• adapt the dosimetry to allow for changing lung volume and critical structure
locations during the breathing cycle.
4-D Treatment tracking framework

Seminars in Radiation Oncology, Vol 14, No 1 ( January), 2004: pp 81-90

VARIAN TRILOGY
NOVALIS/EXAC TRAC
CYBERKNIFE
VERO (BRAINLAB)
Electromagnetic Field Tracking: Calypso system

To induce and detect signals from implanted

wireless devices

Optical tracking system and a tracking station

console

Source coils & sensor coils

Position of transponder without using the

radiographic method

Advantage:

update target position ten times / second &

very fast

sub millimeter tracking accuracy

 MRI based Real-time Volumetric Tracking
• Hybrid MRI-linac & MRI-cobalt-60
machines
• 3 Co-60 source & 0.3 T open field magnet
• MLC system provides gamma-ray intensity
modulation
• MRI
- track a patient's 3-D anatomy every
0.5-2.0s
- superior soft tissue contrast &
- near real-time, volumetric soft tissue
targeting system.
HOKKAIDO UNIVERSITY
FLOROSCOPIC SYSTEM (PRO BEAT)
SITE SPECIFIC MANAGMENT

• LUNG
• LIVER
• PROSTATE
• BREAST
Recommended clinical process for respiratory motion
during the radiotherapy
 Treatment planning margins for various
simulation and treatment devices
Technique GTV CTV PTV

4D CT simulation iGTV ITV = iGTV PTV = ITV + 7 mm

+ 8 mm (setup uncertainty)
Respiratory gating GTV at end CTV = GTV PTV = CTV + 5mm (gating
expiration + 8 mm margin for residual motion)
+ 7 mm (setup uncertainty)
Slow-CT GTV defined CTV = GTV PTV = CTV + 7 mm (setup
simulation by slow CT + 8 mm uncertainty) and
imaging location/sizespecific “tumor
motion” margin
• Set up margins can be reduced to 3 mm if daily CT or 5 mm if daily kV
imaging is performed
LIVER

• Depending on the site of tumor IN THE LIVER movment and

considerations vary
• LIVER MOVES WITH BOTH RESPIRATION AND TO SOME EXTENT WITH
ABDOMINAL MOTION
• Conturing should be done in MIN GENERALLY
• IN LESIONS OF LIVER WHERE SBRT CAN BE OPTED SELECTING THE
APPROPRIATE MOTION MANAGEMENT STRATEGY AND ACCURACY
ARE OF UTMOST IMPORTANCE
 PROSTATE

• EXTENT AND LOCATION

• MOTION IS DUE TO
• STRATEGIES
BAT (b mode
acq & targeting trans
abdominal system)
USG probe is registered to
the stereotactic arm in the
linac gantry
• A TRAIL HAS BEEN DONE BY JANI ET AL
• RECRUTED 50 PTS AND USED BAT
• LESSER RECTAL TOXICITY
• NO DIFFERENCE IN BLADDER TOXICITY AND PSA CONTROL WERE
SEEN
FIDUCIAL IMPLANTATION
CERVIX
• MOTION IS DUE TO
• MOTION ITV AP 1.5 , SI 1.5
LATERALLY 0.7
CONCLUSION
• Although the subject of motion management receives much
attention it is worth noting that its importance in patient
management is surpassed by more fundamental
clinical decisions addressing case selection and
evaluation of accurate radiotherapy
• Only when these are first in place does it makes sense to
tackle the more subtle and technically complex issues of
motion management.
THANK U