Gated Internal Target Volume Concept in Liver patients

treated with Scanned Carbon Ions

Batista V.1, Chaudhri N.2, Richter D.3,4, Jkel, O.1,2,5
1

University Clinic of Heidelberg, Germany

Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
3
University Clinic of Erlangen, Erlangen, Germany
4
GSI Helmholtz Center for Heavy Ion Research, Darmstadt, Germany
5
DKFZ, German Cancer Research Center, Heidelberg, Germany
2

Purpose: Investigate the effect of reduced target margins on the dose distribution in case of residual
target motion during beam gating and abdominal compression.
Methods and materials: 10 patients treated with carbon ion therapy for liver cancer were included in the
study, all immobilized with abdominal compression (AC), additional gating was applied for 5 of them.
Using the GSI TPS TRiP4D, for all patients 4D dose reconstruction for the treated fractions were
performed based on the online-measured breathing signal and the temporal beam delivery sequence.
Retrospectively, for all the patients a gating window for a residual motion below 3 mm was defined,
based on the 4DCT information. We defined an ITVgate corresponding to the union of the phasepropagated CTV within the defined gating window. Treatment plans were optimized for the PTVgate (5mm
expansion of the ITVgate), and for a range-ITV confined to the gating window, ITV gate_WEPL. To assess the
plan quality, the V95%, homogeneity index (HI=D5-D95) of the CTV and the dose to the normal tissues were
determined. The dosimetric accuracy achieved for the reduced PTV was measured for a subset of patients,
in which the peak-to-peak motion was larger than 5 mm. The individual dose verification was performed
in a water phantom, under 3D motion based on the patient breathing trace. The setup included 24
ionization chambers, the Anzai respiratory gating system and a data acquisition system to acquire
temporally correlated motion and beam delivery sequence data. The absorbed dose to water was measured
for the static, free breathing and gating case. Results were compared with the reconstructed dose, and
used as reference for the definition of quality assurance thresholds for moving targets.
Results: For the set of patients the mean peak-to-peak motion vector length was (6.6 3.1) mm. The dose
degradation resulting from residual motion under AC and AC plus gating is presented in the table 1, as the
4D reconstruction results. Also summarized on the table are the results from the 4D dose simulations of
gated treatments from different optimization targets (PTVref, PTVgate, ITVgate_WEPL), where for the
full set of patients the optimization for a PTVgate improved the dose in the normal liver and kidneys, with
no significative reduction of the mean V95.
Dosimetric verifications of these plans showed to be clinically suitable, with mean deviations below 5%.
Conclusions: ITVgate optimization can be used to reduce the dose in the normal tissues when no strong
density changes are observed in the beam path, without compromising the target coverage. With the
inclusion of the WEPL changes into the ITVgate, this can be extended to more patients. The selection of an
adequate surrogate system and the calculation of the 4D dose are key factors to quantify the treatment
quality.
Table 1:

Original Plan:

New Optimization:

4D
Simulated Gated
PTVgate ITVgateWEPL
Reconstruction (for 3mm residual motion)
AC

AC+Gat

V95(%)

94.56.4

96.46.3

98.72.9

98.72.4

HI

10.26.0

6.24.3

4.73.2

4.52.6

Liver

V10(%)

26.79.3

25.88.2

20.412.3

15.29.0

CTV

V95(%)

91.87.7

93.98.5

99.01.2

96.23.5

HI

16.813.6

15.912.9

6.41.6

7.72.0

CTV

Liver

V10(%)

26.89.8

30.66.6

31.24.2

25.23.7