Three-dimensional, Time-Resolved, Intrafraction Motion Monitoring Throughout Stereotactic Liver Radiation Therapy on a Conventional Linear Accelerator

Purpose: To investigate the time-resolved 3-dimensional (3D) internal motion throughout stereotactic body radiation therapy (SBRT) of tumors in the liver using standard x-ray imagers of a conventional linear accelerator. Methods and Materials: Ten patients with implanted gold markers received 11 treatment courses of 3-fraction SBRT in a stereotactic body-frame on a conventional linear accelerator. Two pretreatment and 1 posttreatment cone-beam computed tomography (CBCT) scans were acquired during each fraction. The CBCT projection images were used to estimate the internal 3D marker motion during CBCT acquisition with 11-Hz resolution by a monoscopic probability-based method. Throughout the treatment delivery by conformal or volumetric modulated arc fields, simultaneous MV portal imaging (8 Hz) and orthogonal kV imaging (5 Hz) were applied to determine the 3D marker motion using either MV/kV triangulation or the monoscopic method when marker segmentation was unachievable in either MV or kV images. The accuracy of monoscopic motion estimation was quantified by also applying monoscopic estimation as a test for all treatments during which MV/kV triangulation was possible. Results: Root-mean-square deviations between monoscopic estimations and triangulations were less than 1.0 mm. The mean 3D intrafraction and intrafield motion ranges during liver SBRT were 17.6 mm (range, 5.6-39.5 mm) and 11.3 mm (2.1-35.5 mm), respectively. The risk of large intrafraction baseline shifts correlated with intrafield respiratory motion range. The mean 3D intrafractional marker displacement relative to the first CBCT was 3.4 mm (range, 0.7-14.5 mm). The 3D displacements exceeded 8.8 mm 10% of the time. Conclusions: Highly detailed time-resolved internal 3D motion was determined throughout liver SBRT using standard imaging equipment. Considerable intrafraction motion was observed. The demonstrated methods provide a widely available approach for motion monitoring that, combined with motion-adaptive treatment techniques, has the potential to improve the accuracy of radiation therapy for moving targets. (C) 2013 Elsevier Inc.