Dose calculations accounting for breathing motion in stereotactic lung radiotherapy based on 4D-CT and the internal target volume

Purpose: The purpose of this study was to determine the 4D accumulated dose delivered to the CTV in stereotactic radiotherapy of lung tumours, for treatments planned on an average CT using an ITV derived from the Maximum Intensity Projection (MIP) CT. Methods: For 10 stage 1 lung cancer patients, treatment plans were generated based on 4D-CT images. From the 4D-CT scan, 10 time-sorted breathing phases were derived, along with the average CT and the MIP. The ITV with a margin of 0 mm was used as a PTV to study a worst case scenario in which the differences between 3D planning and 4D dose accumulation will be largest. Dose calculations were performed on the average CT. Dose prescription was 60 Gy to 95% of the PTV, and at least 54 Gy should be received by 99% of the PTV. Plans were generated using the inverse planning module of the Pinnacle 3 treatment planning system. The plans consisted of nine coplanar beams with two segments each. After optimisation, the treatment plan was transferred to all breathing phases and the delivered dose per phase was calculated using an elastic body spline model available in our research version of Pinnacle (8.1r). Then, the cumulative dose to the CTV over all breathing phases was calculated and compared to the dose distribution of the original treatment plan. Results: Although location, tumour size and breathing-induced tumour movement varied widely between patients, the PTV planning criteria could always be achieved without compromising organs at risk criteria. After 4D dose calculations, only very small differences between the initial planned PTV coverage and resulting CTV coverage were observed. For all patients, the dose delivered to 99% of the CTV exceeded 54 Gy. For nine out of 10 patients also the criterion was met that the volume of the CTV receiving at least the prescribed dose was more than 95%. Conclusions: When the target dose is prescribed to the ITV (PTV = ITV) and dose calculations are performed on the average CT, the cumulative CTV dose compares well to the planned dose to the ITV. Thus, the concept of treatment plan optimisation and evaluation based on the average CT and the ITV is a valid approach in stereotactic lung treatment. Even with a zero ITV to PTV margin, no significantly different dose coverage of the CTV arises from the breathing motion induced dose variation over time. (C) 2007 Elsevier Ireland Ltd. All rights reserved.