The precision of respiratory-gated delivery of synchrotron-based pulsed beam proton therapy.

A synchrotron-based proton therapy system operates in a low repetition rate pulsed beam delivery mode. Unlike cyclotron-based beam delivery, there is no guarantee that a synchrotron beam can be delivered effectively or precisely under the respiratory-gated mode. To evaluate the performance of gated synchrotron treatment, we simulated proton beam delivery in the synchrotron-based respiratory-gated mode using realistic patient breathing signals. Parameters used in the simulation were respiratory motion traces (70 traces from 24 patients), respiratory gate levels (10%, 20% and 30% duty cycles at the exhalation phase) and synchrotron magnet excitation cycles (T(cyc)) (fixed T(cyc) mode: 2.7, 3.0-6.0 s and each patient breathing cycle, and variable T(cyc) mode). The simulations were computed according to the breathing trace in which the proton beams were delivered. In the shorter fixed T(cyc) (<4 s), most of the proton beams were delivered uniformly to the target during the entire expiration phase of the respiratory cycle. In the longer fixed T(cyc) (>4 s) and the variable T(cyc) mode, the proton beams were not consistently delivered during the end-expiration phase of the respiratory cycle. However we found that the longer and variable T(cyc) operation modes delivered proton beams more precisely during irregular breathing.

Efficiency of respiratory-gated delivery of synchrotron-based pulsed proton irradiation.

Significant differences exist in respiratory-gated proton beam delivery with a synchrotron-based accelerator system when compared to photon therapy with a conventional linear accelerator. Delivery of protons with a synchrotron accelerator is governed by a magnet excitation cycle pattern. Optimal synchronization of the magnet excitation cycle pattern with the respiratory motion pattern is critical to the efficiency of respiratory-gated proton delivery. There has been little systematic analysis to optimize the accelerator's operational parameters to improve gated treatment efficiency. The goal of this study was to estimate the overall efficiency of respiratory-gated synchrotron-based proton irradiation through realistic simulation. Using 62 respiratory motion traces from 38 patients, we simulated respiratory gating for duty cycles of 30%, 20% and 10% around peak exhalation for various fixed and variable magnet excitation patterns. In each case, the time required to deliver 100 monitor units in both non-gated and gated irradiation scenarios was determined. Based on results from this study, the minimum time required to deliver 100 MU was 1.1 min for non-gated irradiation. For respiratory-gated delivery at a 30% duty cycle around peak exhalation, corresponding average delivery times were typically three times longer with a fixed magnet excitation cycle pattern. However, when a variable excitation cycle was allowed in synchrony with the patient's respiratory cycle, the treatment time only doubled. Thus, respiratory-gated delivery of synchrotron-based pulsed proton irradiation is feasible and more efficient when a variable magnet excitation cycle pattern is used.

Correlation between internal fiducial tumor motion and external marker motion for liver tumors imaged with 4D-CT.

PURPOSE: We investigated the correlation between the motions of an external marker and internal fiducials implanted in the liver for 8 patients undergoing respiratory-based computed tomography (four-dimensional CT [4D-CT]) procedures. METHODS AND MATERIALS: The internal fiducials were gold seeds, 3 mm in length and 1.2 mm in diameter. Four patients each had one implanted fiducial, and the other four had three implanted fiducials. The external marker was a plastic box, which is part of the Real-Time Position Management System (RPM) used to track the patient's respiration. Each patient received a standard helical CT scan followed by a time-correlated CT-image acquisition (4D-CT). The 4D-CT images were reconstructed in 10 separate phases covering the entire respiratory cycle. RESULTS: The internal fiducial motion is predominant in the superior-inferior direction, with a range of 7.5-17.5 mm. The correlation between external respiration and internal fiducial motion is best during expiration. For 2 patients with their three fiducials separated by a maximum of 3.2 cm, the motions of the fiducials were well correlated, whereas for 2 patients with more widely spaced fiducials, there was less correlation. CONCLUSIONS: In general, there is a good correlation between internal fiducial motion imaged by 4D-CT and external marker motion. We have demonstrated that gating may be best performed at the end of the respiratory cycle. Special attention should be paid to gating for patients whose fiducials do not move in synchrony, because targeting on the correct respiratory amplitude alone would not guarantee that the entire tumor volume is within the treatment field.

Correlation between the respiratory waveform measured using a respiratory sensor and 3D tumor motion in gated radiotherapy.

PURPOSE: The purpose of this study is to investigate the correlation between the respiratory waveform measured using a respiratory sensor and three-dimensional (3D) tumor motion. METHODS AND MATERIALS: A laser displacement sensor (LDS: KEYENCE LB-300) that measures distance using infrared light was used as the respiratory sensor. This was placed such that the focus was in an area around the patient's navel. When the distance from the LDS to the body surface changes as the patient breathes, the displacement is detected as a respiratory waveform. To obtain the 3D tumor motion, a biplane digital radiography unit was used. For the tumor in the lung, liver, and esophagus of 26 patients, the waveform was compared with the 3D tumor motion. The relationship between the respiratory waveform and the 3D tumor motion was analyzed by means of the Fourier transform and a cross-correlation function. RESULTS: The respiratory waveform cycle agreed with that of the cranial-caudal and dorsal-ventral tumor motion. A phase shift observed between the respiratory waveform and the 3D tumor motion was principally in the range 0.0 to 0.3 s, regardless of the organ being measured, which means that the respiratory waveform does not always express the 3D tumor motion with fidelity. For this reason, the standard deviation of the tumor position in the expiration phase, as indicated by the respiratory waveform, was derived, which should be helpful in suggesting the internal margin required in the case of respiratory gated radiotherapy. CONCLUSION: Although obtained from only a few breathing cycles for each patient, the correlation between the respiratory waveform and the 3D tumor motion was evident in this study. If this relationship is analyzed carefully and an internal margin is applied, the accuracy and convenience of respiratory gated radiotherapy could be improved by use of the respiratory sensor.Thus, it is expected that this procedure will come into wider use.

Modeling of daily operation in proton radiotherapy by Monte Carlo method.

A simple model for efficiency analysis of daily operation in proton radiotherapy is applied to numerical calculation with fixed time advancing. For the simplifying, man power is assumed to be enough and troubles in the equipments are ignored. To generate random numbers which become the time for adjusting the patient position and for waiting the next patient, typical probability distributions are utilized in the simulation. By using the simulation, treatment capacity of a facility is estimated for different number of treatment rooms to know the efficient number of gantries for proton radiotherapy.

[Respiration gated CT scanning for radiation treatment planning by guided respiration method].

In Proton Medical Research Center (PMRC), we have performed the respiration-gated irradiation for treating the tumor in the body trunk. In the conventional method, patients must hold their expiration during CT scanning. The phase of holding expiration is different from the end-expiration phase. This results in difference of anatomical location in the body between CT scanning and the respiration-gated irradiation. For the sake of highly-accurate irradiation, a respiration gated CT scanning system is introduced. In case of natural respiration, it has been difficult to achieve the gated CT scanning because a stable period of end-expiratory is not so long as CT scanning time (1 second in our case). In this study, we developed a guided respiration method, which leads a patient to maintain the end-expiratory phase during required time. The respiration gated CT scanning is performed by using this. The phase of the acquired CT image can be approximated to that of respiration-gated irradiation.

The direct measurement using an imaging plate for coincidence of radiation centre and laser position in external radiation therapy.

A new method of quality assurance has been studied to measure coincidence of the radiation centre and a patient-setup laser position on a transverse plane to the beam at the isocentre. This measurement is achieved by using an imaging plate (IP). When radiation is applied to an IP, the energy is stored as trapped electrons. The number of electrons is decreased by local laser exposure. As a result, the radiation field produced by external beam irradiation is recorded as 'positive' information and the position of the patient-setup laser is recorded as 'negative' on an IP. The advantages of this method are the direct measurement, short time and high resolution. These are required for daily and monthly quality checks. We confirmed the advantage of this method by an experiment using a proton beam.