The use of active breathing control (ABC) to reduce margin for breathing motion

A Prospective Study on Deep Inspiration Breath Hold Thoracic Radiation Therapy Guided by Bronchoscopically Implanted Electromagnetic Transponders

BACKGROUND

Electromagnetic transponders bronchoscopically implanted near the tumor can be used to monitor deep inspiration breath hold (DIBH) for thoracic radiation therapy (RT). The feasibility and safety of this approach require further study.

METHODS

We enrolled patients with primary lung cancer or lung metastases. Three transponders were implanted near the tumor, followed by simulation with DIBH, free breathing, and 4D-CT as backup. The initial gating window for treatment was ±5 mm; in a second cohort, the window was incrementally reduced to determine the smallest feasible gating window. The primary endpoint was feasibility, defined as completion of RT using transponder-guided DIBH. Patients were followed for assessment of transponder- and RT-related toxicity.

RESULTS

We enrolled 48 patients (35 with primary lung cancer and 13 with lung metastases). The median distance of transponders to tumor was 1.6 cm (IQR 0.6-2.8 cm). RT delivery ranged from 3 to 35 fractions. Transponder-guided DIBH was feasible in all but two patients (96% feasible), where it failed because the distance between the transponders and the antenna was >19 cm. Among the remaining 46 patients, 6 were treated prone to keep the transponders within 19 cm of the antenna, and 40 were treated supine. The smallest feasible gating window was identified as ±3 mm. Thirty-nine (85%) patients completed one year of follow-up. Toxicities at least possibly related to transponders or the implantation procedure were grade 2 in six patients (six incidences, cough and hemoptysis), grade 3 in three patients (five incidences, cough, dyspnea, pneumonia, and supraventricular tachycardia), and grade 4 pneumonia in one patient (occurring a few days after implantation but recovered fully and completed RT). Toxicities at least possibly related to RT were grade 2 in 18 patients (41 incidences, most commonly cough, fatigue, and pneumonitis) and grade 3 in four patients (seven incidences, most commonly pneumonia), and no patients had grade 4 or higher toxicity.

CONCLUSIONS

Bronchoscopically implanted electromagnetic transponder-guided DIBH lung RT is feasible and safe, allowing for precise tumor targeting and reduced normal tissue exposure. Transponder-antenna distance was the most common challenge due to a limited antenna range, which could sometimes be circumvented by prone positioning.

Novel utilization and quantification of Xsight diaphragm tracking for respiratory motion compensation in Cyberknife Synchrony treatment of liver tumors

PURPOSE

The Xsight lung tracking system (XLTS) utilizes an advanced image processing algorithm to precisely identify the position of a tumor and determine its location in orthogonal x-ray images, instead of finding fiducials, thereby minimizing the risk of fiducial insertion-related side effects. To assess and gauge the effectiveness of CyberKnife Synchrony in treating liver tumors located in close proximity to or within the diaphragm, we employed the Xsight diaphragm tracking system (XDTS), which was based on the XLTS.

METHODS

We looked back at the treatment logs of 11 patients (8/11 [XDTS], 3/11 [Fiducial-based Target Tracking System-FTTS]) who had liver tumors in close proximity to or within the diaphragm. And the results are compared with the patients who undergo the treatment of FTTS. The breathing data information was calculated as a rolling average to reduce the effect of irregular breathing. We tested the tracking accuracy with a dynamic phantom (18023-A) on the basis of patient-specific respiratory curve.

RESULTS

The average values for the XDTS and FTTS correlation errors were 1.38 ± 0.65  versus 1.50 ± 0.26 mm (superior-inferior), 1.28 ± 0.48  versus 0.40 ± 0.09 mm (left-right), and 0.96 ± 0.32  versus 0.47 ± 0.10 mm(anterior-posterior), respectively. The prediction errors for two methods of 0.65 ± 0.16  versus 5.48 ± 3.33 mm in the S-I direction, 0.34 ± 0.10  versus 1.41 ± 0.76 mm in the A-P direction, and 0.22 ± 0.072  versus 1.22 ± 0.48 mm in the L-R direction. The coverage rate of FTTS slightly less than that of XDTS, such as 96.53 ± 8.19% (FTTS) versus 98.03 ± 1.54 (XDTS). The prediction error, the motion amplitude, and the variation of the respiratory center phase were strongly related to each other. Especially, the higher the amplitude and the variation, the higher the prediction error.

CONCLUSION

The diaphragm has the potential to serve as an alternative to gold fiducial markers for detecting liver tumors in close proximity or within it. We also found that we needed to reduce the motion amplitude and train the respiration of the patients during liver radiotherapy, as well as control and evaluate their breathing.

Deep inspiration breath hold real-time tumor-tracking radiation therapy (DBRT) as a novel stereotactic body radiation therapy approach for lung tumors

Radiotherapy with deep inspiration breath hold (DIBH) reduces doses to the lungs and organs at risk. The stability of breath holding and reproducibility of tumor location are higher during expiration than during inspiration; therefore, we developed an irradiation method combining DIBH and real-time tumor-tracking radiotherapy (RTRT) (DBRT). Nine patients were enrolled in this study. Fiducial markers were placed near tumors using bronchoscopy. Treatment planning computed tomography (CT) was performed thrice during DIBH, assisted by spirometer-based device. Each CT scan was fused using fiducial markers. Gross tumor volume (GTV) was contoured for each dataset and summed to create GTVsum; adding a 5-mm margin around GTVsum generated the planning target volume. The prescribed dose was mainly 42 Gy in four fractions. The treatment plan was created using DIBH CT (DBRT-plan), with a similar treatment plan created for expiratory CT for cases for which DBRT could not be performed (conv-plan). Vx defined as the volume of the lung received x Gy, and the mean lung dose, V20, V10, and V5 were evaluated. DBRT was completed in all patients. Mean dose, V20, and V10 were significantly lower in the DBRT-plan than in the conv-plan (all p = 0.003). Mean rates of decrease for mean dose, V20, and V10 were 14.0%, 27.6%, and 19.1%, respectively. No significant difference was observed in V5. We developed DBRT, a stereotactic body radiation therapy performed with the DIBH technique; it combines a spirometer-based breath-hold support system with an RTRT system. All patients who underwent DBRT completed the procedure without any technical or mechanical complications. This is a promising methodology that may significantly reduce lung doses.

The first clinical implementation of real-time 6 degree-of-freedom image-guided radiotherapy for liver SABR patients

PURPOSE

Multiple survey results have identified a demand for improved motion management for liver cancer IGRT. Until now, real-time IGRT for liver has been the domain of dedicated and expensive cancer radiotherapy systems. The purpose of this study was to clinically implement and characterise the performance of a novel real-time 6 degree-of-freedom (DoF) IGRT system, Kilovoltage Intrafraction Monitoring (KIM) for liver SABR patients.

METHODS/MATERIALS

The KIM technology segmented gold fiducial markers in intra-fraction x-ray images as a surrogate for the liver tumour and converted the 2D segmented marker positions into a real-time 6DoF tumour position. Fifteen liver SABR patients were recruited and treated with KIM combined with external surrogate guidance at three radiotherapy centres in the TROG 17.03 LARK multi-institutional prospective clinical trial. Patients were either treated in breath-hold or in free breathing using the gating method. The KIM localisation accuracy and dosimetric accuracy achieved with KIM + external surrogate were measured and the results were compared to those with the estimated external surrogate alone.

RESULTS

The KIM localisation accuracy was 0.2±0.9 mm (left-right), 0.3±0.6 mm (superior-inferior) and 1.2±0.8 mm (anterior-posterior) for translations and -0.1◦±0.8◦ (left-right), 0.6◦±1.2◦ (superior-inferior) and 0.1◦±0.9◦ (anterior-posterior) for rotations. The cumulative dose to the GTV with KIM + external surrogate was always within 5% of the plan. In 2 out of 15 patients, >5% dose error would have occurred to the GTV and an organ-at-risk with external surrogate alone.

CONCLUSIONS

This work demonstrates that real-time 6DoF IGRT for liver can be implemented on standard radiotherapy systems to improve treatment accuracy and safety. The observations made during the treatments highlight the potential false assurance of using traditional external surrogates to assess tumour motion in patients and the need for ongoing improvement of IGRT technologies.

Investigation of Intra-fraction Stability and Inter-fraction Consistency of Active Breathing Coordinator (ABC)-Based Deep Inspiration Breath Holds in Left-Sided Breast Cancer

Background Deep inspiration breath-hold (DIBH) has been established as a standard technique to reduce cardiac dose. The part of the heart exposed to radiation can be significantly decreased using the DIBH technique during tangential left-sided breast cancer (LSBC) irradiation. Aim The objective of this study was to investigate the intra-fraction breath-hold stability and inter-fraction consistency of patient breath-hold against the threshold as a function of air volumes in the setting of active breathing coordinator (ABC)-based DIBH (ABC-DIBH) treatment to LSBC. Methods A total of 34 patients treated with external beam radiation therapy (EBRT) to the left breast using the ABC-DIBH device were included. The frequency of breath-holds per fraction and the entire course of treatment along with the total treatment time was evaluated for all patients. A prescription dose of either 200 cGy (conventional) or 267 cGy (hypofractionation) was administered during 649 fractions, resulting in a total of 4,601 breath-hold measurements being evaluated. The amplitude of deviation in terms of air volumes between the baseline threshold and the patient-specific measurement (during each breath-hold) per fraction was used to define the DIBH stability. Likewise, the consistency of the breathing amplitudes was used to define the compliance of patient breath-holds throughout the entire treatment period. Positional accuracy was evaluated using orthogonal (portal) images. Results The average number of breath-holds measured over the entire course of treatment for each patient was 144 inspirations (58-351). Similarly, the average number of breath-holds for each fraction during the course of treatment was 11 inspirations (7-21), which included setup imaging and treatment. The total number of breath-holds reduced significantly (p-value < 0.05) with hypofractionation (104 inspirations; range 58-170) as compared to conventional fractionation (145 inspirations; 58-351). The average breath-hold threshold in terms of air volume was 1.41 L (0.6-2.1 L) for all patients. The total treatment time reduced significantly after the third fraction (p-value < 0.05). The average deviation between the measured and baseline threshold breath-holds during the course of treatment was 0.5 L/sec (0.12-1.32 L/sec). The consistency of the breathing amplitudes were maintained within ±0.05 L during the entire treatment for all patients. The average translational shifts measured during setup were 0.28 cm ± 0.3 cm, 0.38 cm ± 0.4 cm, and 0.21 cm ± 0.3 cm in the lateral, longitudinal, and vertical directions, respectively. Conclusion The study has demonstrated the variations in intra-fraction breath-hold stability and inter-fraction breath-hold consistency in terms of air volumes for patients who were treated for LSBC. The frequency of breath-holds was observed to be higher with increased total treatment time for the first few fractions and reduced over the course of treatment.

Online verification of breath-hold reproducibility using kV-triggered imaging for liver stereotactic body radiation therapy

PURPOSE

To introduce a new technique for online breath-hold verification for liver stereotactic body radiation therapy (SBRT) based on kilovoltage-triggered imaging and liver dome positions.

MATERIAL AND METHODS

Twenty-five liver SBRT patients treated with deep inspiration breath-hold were included in this IRB-approved study. To verify the breath-hold reproducibility during treatment, a KV-triggered image was acquired at the beginning of each breath-hold. The liver dome position was visually compared with the expected upper/lower liver boundaries created by expanding/contracting the liver contour 5 mm in the superior-inferior direction. If the liver dome was within the boundaries, delivery continued; otherwise, beam was held manually, and the patient was instructed to take another breath-hold until the liver dome fell within boundaries. The liver dome was delineated on each triggered image. The mean distance between the delineated liver dome to the projected planning liver contour was defined as liver dome position error edome . The mean and maximum edome of each patient were compared between no breath-hold verification (all triggered images) and with online breath-hold verification (triggered images without beam-hold).

RESULTS

Seven hundred thirteen breath-hold triggered images from 92 fractions were analyzed. For each patient, an average of 1.5 breath-holds (range 0-7 for all patients) resulted in beam-hold, accounting for 5% (0-18%) of all breath-holds; online breath-hold verification reduced the mean edome from 3.1 mm (1.3-6.1 mm) to 2.7 mm (1.2-5.2 mm) and the maximum edome from 8.6 mm (3.0-18.0 mm) to 6.7 mm (3.0-9.0 mm). The percentage of breath-holds with edome >5 mm was reduced from 15% (0-42%) without breath-hold verification to 11% (0-35%) with online breath-hold verification. online breath-hold verification eliminated breath-holds with edome >10 mm, which happened in 3% (0-17%) of all breath-holds.

CONCLUSION

It is clinically feasible to monitor the reproducibility of each breath-hold during liver SBRT treatment using triggered images and liver dome. Online breath-hold verification improves the treatment accuracy for liver SBRT.

ESTRO-ACROP guideline: Recommendations on implementation of breath-hold techniques in radiotherapy

The use of breath-hold techniques in radiotherapy, such as deep-inspiration breath hold, is increasing although guidelines for clinical implementation are lacking. In these recommendations, we aim to provide an overview of available technical solutions and guidance for best practice in the implementation phase. We will discuss specific challenges in different tumour sites including factors such as staff training and patient coaching, accuracy, and reproducibility. In addition, we aim to highlight the need for further research in specific patient groups. This report also reviews considerations for equipment, staff training and patient coaching, as well as image guidance for breath-hold treatments. Dedicated sections for specific indications, namely breast cancer, thoracic and abdominal tumours are also included.

Efficacy of preoxygenation administration in volunteers, in extending the end-expiration breath-hold duration for application to abdominal radiotherapy

Background and purpose

End expiration breath hold (EEBH) is the preferred motion management method for abdominal Stereotactic Ablative Body Radiotherapy (SABR) treatments. However, multiple short EEBHs are required to complete a single treatment session. The study aimed to determine the efficacy of preoxygenation with hyperventilation in extending an EEBH duration.

Materials and methods

We randomised 10 healthy participants into two arms, each included breathing room air and oxygen at a rate of 10 L per minute (l/min) without hyperventilation for four minutes, and normally for four minutes and with hyperventilation for one minute at a rate of 20 breaths/minute for hyperventilation. The type of gas was blinded from the participants for each test. EEBH durations were then recorded, as well as systolic blood pressure, SpO₂ and heart rate. A discomfort rating was also recorded after each breath hold.

Results

A significant increase in duration of almost 50% was observed between normal breathing of room air and breathing oxygen normally followed by hyperventilation. Vital signs remained consistent between the 4 tests. The tests were well tolerated with 75% of participants recording none or minimal discomfort.

Conclusion

Preoxygenation with hyperventilation could be used to increase the EEBH duration for abdominal SABR patients which would assist in the accuracy of these treatments and possibly resulting in a reduction of overall treatment times.

Deep Inspiratory Breath-Hold Radiation for Left-Sided Breast Cancer using Novel Frame-based Tactile Feedback

A frame providing tactile feedback for the reproducibility of deep inspiratory breath-hold (DIBH) is described. The frame, fitted across the patient, comprises a horizontal bar, parallel to the patient's long axis, and holds a graduated pointer perpendicular to it. The pointer provides individualized tactile feedback for reproducibility of DIBH. Within the pointer is a movable pencil, bearing a 5 mm coloured strip which becomes visible only during DIBH, and acts as a visual cue to the therapist. The average variation in separation in the planning and pretreatment cone-beam computed tomography of 10 patients was 2 mm (confidence interval 1.95-2.05). Frame-based tactile feedback is a novel, reproducible technique for DIBH.

Accuracy and potential improvements of surface-guided breast cancer radiotherapy in deep inspiration breath-hold with daily image-guidance

Objective. Radiotherapy of left-sided breast cancer in deep inspiration breath-hold (DIBH) reduces the heart dose. Surface guided radiotherapy (SGRT) can guide the DIBH, but the accuracy is subject to variations in the chest wall position relative to the patient surface. Approach. In this study, ten left-sided breast cancer patients received DIBH radiotherapy with tangential fields in 15–18 fractions. After initial SGRT setup in free breathing an orthogonal MV/kV image pair was acquired during SGRT-guided breath-hold. The couch was corrected to align the chest wall during another breath-hold, and a new SGRT reference surface was acquired for the gating. The chest wall position error during treatment was determined from continuous cine MV images in the imager direction perpendicular to the cranio-caudal direction. A treatment error budget was made with individual contributions from the online registration of the setup MV image, the difference in breath-hold level between setup imaging and SGRT reference surface acquisition, the SGRT level during treatment, and intra-fraction shifts of the chest wall relative to the SGRT reference surface. In addition to the original setup protocol (Scenario A), SGRT was also simulated with better integration of image-guidance by capturing either the new reference surface (Scenario B) or the SGRT positional signal (Scenario C) simultaneously with the setup MV image, and accounting for the image-guided couch correction by shifting the SGRT reference surface digitally. Main results. In general, the external SGRT signal correlated well with the internal chest wall position error (correlation coefficient >0.7 for 75% of field deliveries), but external-to-internal target position offsets above 2 mm occasionally occurred (13% of fractions). The PTV margin required to account for the treatment error was 3.5 mm (Scenario A), 3.4 mm (B), and 3.1 mm (C). Significance. Further integration of SGRT with image-guidance may improve treatment accuracy and workflow although the current study did not show large accuracy improvements of scenario B and C compared to scenario A.

Statistical evaluation of the effectiveness of dual amplitude-gated stereotactic body radiotherapy using fiducial markers and lung volume

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Approximately 30% of the fiducial markers demonstrated a low correlation on comparing lung volumes.

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Monitoring of lung volume can achieve stable tracking of lung tumors.

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Dual monitoring by employing the marker and lung volume may possibly avoid the deterioration of monitoring accuracy.

Background and purpose

The low tracking accuracy of lung stereotactic body radiotherapy (SBRT) risks reduced treatment efficacy. We used four-dimensional computed tomography (4DCT) images to determine the correlation between changes in fiducial marker positions and lung volume for lung tumors, and we evaluated the effectiveness of the combined use of these images in lung SBRT.

Materials and methods

Data of 30 patients who underwent fiducial marker placement were retrospectively analyzed. We calculated the motion amplitudes of the center of gravity coordinates of the lung tumor and fiducial markers in each phase and the ipsilateral, contralateral, and bilateral lung volumes using 4DCT. Moreover, we calculated the cross-correlation coefficient between the fiducial marker position and the lung volume changes waveform for the motion amplitude waveform of the lung tumor over three gating windows (all phases, ≤2 mm³, and ≤3 mm³).

Results

Compared with the lung volume, approximately 30 % of the fiducial markers demonstrated a low correlation with the lung tumor. In the ≤2 mm³ and ≤3 mm³ gating windows, the cross-correlation coefficients between the lung tumor and the optimal marker (r > 0.9: 83 % and 86 %) were significantly different for all fiducial markers (r > 0.9: 39 %, 53 %) and the ipsilateral (r > 0.9: 35 % and 40 %), contralateral (r > 0.9: 44 % and 41 %), and bilateral (r > 0.9: 39 % and 45 %) lung volumes.

Conclusions

Some of the fiducial markers showed a low correlation with the lung tumor. This study indicated that the combined use of lung volume monitoring can improve tracking accuracy.

Predicting respiratory motion using a novel patient specific dual deep recurrent neural networks

Real-time tracking of a target volume is a promising solution for reducing the planning margins and both dosimetric and geometric uncertainties in the treatment of thoracic and upper-abdomen cancers. Respiratory motion prediction is an integral part of real-time tracking to compensate for the latency of tracking systems. The purpose of this work was to develop a novel method for accurate respiratory motion prediction using dual deep recurrent neural networks (RNNs). The respiratory motion data of 111 patients were used to train and evaluate the method. For each patient, two models (Network1 and Network2) were trained on 80% of the respiratory wave, and the remaining 20% was used for evaluation. The first network (Network 1) is a "coarse resolution" prediction of future points and second network (Network 2) provides a "fine resolution" prediction to interpolate between the future predictions. The performance of the method was tested using two types of RNN algorithms : Long Short-Term Memory (LSTM) and Gated Recurrent Unit (GRU). The accuracy of each model was evaluated using the root mean square error (RMSE) and mean absolute error (MAE). Overall, the RNN model with GRU- function had better accuracy than the RNN model with LSTM-function (RMSE (mm): 0.4±0.2 vs. 0.6±0.3; MAE (mm): 0.4±0.2 vs. 0.6±0.2). The GRU was able to predict the respiratory motion accurately (<1 mm) up to the latency period of 440 ms, and LSTM's accuracy was acceptable only up to 240 ms. The proposed method using GRU function can be used for respiratory-motion prediction up to a latency period of 440 ms.

Active breathing control guided stereotactic body ablative radiotherapy for management of liver metastases from colorectal cancer

Background: Liver metastases may occur during the course of several cancer types and may be associated with significant morbidity and mortality. There is paucity of data regarding the utility of Active Breathing Control (ABC) guided Stereotactic Ablative Body Radiotherapy (SABR) for management of Liver Metastases from Colorectal Cancer (LMCC). Our aim is to investigate the role of ABC guided SABR for management of liver metastases Patients and methods: 42 liver metastases of 29 patients treated with ABC guided SABR between February 2015 and October 2018 were retrospectively assessed for local control (LC), overall survival (OS), and toxicity outcomes. Primary endpoint was LC. Secondary endpoints were OS and treatment toxicity. Results: At a median follow up duration of 16 months (range: 9-74 months), median OS was 20 months and 3 patients were still alive at last follow up. 1-year OS was 83% and 2-year OS was 28%. LC rates were 92% and 61% at 1 and 2 years, respectively. Comparative analysis of Biological Effective Dose (BED) values revealed that higher BED10 values were associated with higher LC rates (p=0.007). While LC rates for BED10 ≥ 100 Gray (Gy) were 94% and 86% at 1 and 2 years, corresponding LC rates for BED10 < 100 Gy were 89% and 36%, respectively with statistical significance (p=0.007). Assessment of acute and late toxicity outcomes revealed that most common toxicity was fatigue, however, no patients had ≥ grade 3 toxicity. Conclusion: ABC guided SABR is an effective and safe treatment modality for LMCC management.

Reproducibility of chestwall and heart position using surface-guided versus RPM-guided DIBH radiotherapy for left breast cancer

This study compared the reproducibility of chestwall and heart position using surface-guided versus RPM (real-time position management)-guided deep inspiration breath hold (DIBH) radiotherapy for left sided breast cancer. Forty DIBH patients under either surface-guided radiotherapy (SGRT) or RPM guidance were studied. For patients treated with tangential fields, reproducibility was measured as the displacements in central lung distance (CLD) and heart shadow to field edge distance (HFD) between pretreatment MV (megavoltage) images and planning DRRs (digitally reconstructed radiographs). For patients treated with volumetric modulated arc therapy (VMAT), sternum to isocenter (ISO) distance (StID), spine to rib edge distance (SpRD), and heart shadow to central axis (CAX) distance (HCD) between pretreatment kV images and planning DRRs were measured. These displacements were compared between SGRT and RPM-guided DIBH. In tangential patients, the mean absolute displacements of SGRT versus RPM guidance were 0.19 versus 0.23 cm in CLD, and 0.33 versus 0.62 cm in HFD. With respect to planning DRR, heart appeared closer to the field edge by 0.04 cm with surface imaging versus 0.62 cm with RPM. In VMAT patients, the displacements of surface imaging versus RPM guidance were 0.21 versus 0.15 cm in StID, 0.24 versus 0.19 cm in SpRD, and 0.72 versus 0.41 cm in HCD. Heart appeared 0.41 cm further away from CAX with surface imaging, whereas 0.10 cm closer to field CAX with RPM. None of the differences between surface imaging and RPM guidance was statistically significant. In conclusion, the displacements of chestwall were small and were comparable with SGRT- or RPM-guided DIBH. The position deviations of heart were larger than those of chestwall with SGRT or RPM. Although none of the differences between SGRT and RPM guidance were statistically significant, there was a trend that the position deviations of heart were smaller and more favorable with SGRT than with RPM guidance in tangential patients.

Intrafractional accuracy and efficiency of a surface imaging system for deep inspiration breath hold during ablative gastrointestinal cancer treatment

PURPOSE

Beam gating with deep inspiration breath hold (DIBH) usually depends on some external surrogate to infer internal target movement, and the exact internal movement is unknown. In this study, we tracked internal targets and characterized residual motion during DIBH treatment, guided by a surface imaging system, for gastrointestinal cancer. We also report statistics on treatment time.

METHODS AND MATERIALS

We included 14 gastrointestinal cancer patients treated with surface imaging-guided DIBH volumetrically modulated arc therapy, each with at least one radiopaque marker implanted near or within the target. They were treated in 25, 15, or 10 fractions. Thirteen patients received treatment for pancreatic cancer, and one underwent separate treatments for two liver metastases. The surface imaging system monitored a three-dimensional surface with ± 3 mm translation and ± 3° rotation threshold. During delivery, a kilovolt image was automatically taken every 20° or 40° gantry rotation, and the internal marker was identified from the image. The displacement and residual motion of the markers were calculated. To analyze the treatment efficiency, the treatment time of each fraction was obtained from the imaging and treatment timestamps in the record and verify system.

RESULTS

Although the external surface was monitored and limited to ± 3 mm and ± 3°, significant residual internal target movement was observed in some patients. The range of residual motion was 3-21 mm. The average displacement for this cohort was 0-3 mm. In 19% of the analyzed images, the magnitude of the instantaneous displacement was > 5 mm. The mean treatment time was 17 min with a standard deviation of 4 min.

CONCLUSIONS

Precaution is needed when applying surface image guidance for gastrointestinal cancer treatment. Using it as a solo DIBH technique is discouraged when the correlation between internal anatomy and patient surface is limited. Real-time radiographic verification is critical for safe treatments.

Quality assurance of a breathing controlled four-dimensional computed tomography algorithm

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Initial quality assurance of a novel breathing-controlled four-dimensional computed tomography algorithm.

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Assessment of geometry, motion representation and image quality for regular and irregular breathing.

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No clinically relevant differences in results for regular and irregular breathing.

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Only minor differences in tumor geometry representation and image quality compared to static three-dimensional computed tomography.

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Table flexion has no clinically relevant impact on geometry representation.

Background & purpose

Material & methods

Results

Conclusions

Heart Sparing Radiotherapy Techniques in Breast Cancer: A Focus on Deep Inspiration Breath Hold

Adjuvant radiation therapy is a critical component of breast cancer management. However, when breast cancer patients receive incidental radiation to the heart, there is an increased risk of cardiac disease and mortality. This is most common for patients with left-sided breast cancers and those receiving nodal irradiation as part of treatment. The overall risk of cardiac toxicity increases 4–16% with each Gray increase in mean heart radiation dose, with data suggesting that no lower limit exists which would eliminate cardiac risk entirely. Radiation techniques have improved over time, leading to lower cardiac radiation exposure than in the past. This decline is expected to reduce the incidence of radiation-induced heart dysfunction in patients. Deep inspiration breath hold (DIBH) is one such technique that was developed to reduce the risk of cardiac death and coronary events. DIBH is a non-invasive approach that capitalizes on the natural physiology of the respiratory cycle to increase the distance between the heart and the therapeutic target throughout the course of radiation therapy. DIBH has been shown to decrease the mean incidental radiation doses to the heart and left anterior descending coronary artery by approximately 20–70%. In this review, we summarize different techniques for DIBH and discuss recent data on this technique.

Evaluating Proton Dose and Associated Range Uncertainty Using Daily Cone-Beam CT

Purpose

This study aimed to quantitatively evaluate the range uncertainties that arise from daily cone-beam CT (CBCT) images for proton dose calculation compared to CT using a measurement-based technique.

Methods

For head and thorax phantoms, wedge-shaped intensity-modulated proton therapy (IMPT) treatment plans were created such that the gradient of the wedge intersected and was measured with a 2D ion chamber array. The measured 2D dose distributions were compared with 2D dose planes extracted from the dose distributions using the IMPT plan calculated on CT and CBCT. Treatment plans of a thymoma cancer patient treated with breath-hold (BH) IMPT were recalculated on 28 CBCTs and 9 CTs, and the resulting dose distributions were compared.

Results

The range uncertainties for the head phantom were determined to be 1.2% with CBCT, compared to 0.5% for CT, whereas the range uncertainties for the thorax phantom were 2.1% with CBCT, compared to 0.8% for CT. The doses calculated on CBCT and CT were similar with similar anatomy changes. For the thymoma patient, the primary source of anatomy change was the BH uncertainty, which could be up to 8 mm in the superior-inferior (SI) direction.

Conclusion

We developed a measurement-based range uncertainty evaluation method with high sensitivity and used it to validate the accuracy of CBCT-based range and dose calculation. Our study demonstrated that the CBCT-based dose calculation could be used for daily dose validation in selected proton patients.

Intrafraction target shift comparison using two breath-hold systems in lung stereotactic body radiotherapy

Background and purpose

In lung Stereotactic Body Radiotherapy (SBRT) respiratory management is used to reduce target motion due to respiration. This study aimed (1) to estimate intrafraction shifts through a Cone Beam Computed Tomography (CBCT) acquired during the first treatment arc when deep inspiration breath-hold (DIBH) was performed using spirometry-based (SB) or surface-guidance (SG) systems and (2) to analyze the obtained results depending on lesion localization.

Material and methods

A sample of 157 patients with 243 lesions was analyzed. A total of 860 and 410 fractions were treated using SB and SG. Averaged intrafraction shifts were estimated by the offsets obtained when registering a CBCT acquired during the first treatment arc with the planning CT. Offsets were recorded in superior-inferior (SI), left-right (LR) and anterior-posterior (AP). Significance tests were applied to account for differences in average offsets and variances between DIBH systems. Systematic and random errors were computed.

Results

Average offset moduli were 2.4 ± 2.2 mm and 3.5 ± 2.6 mm for SB and SG treatments (p < 0.001). When comparing SB and SG offset distributions in each direction no differences were found in average values (p > 0.3). However, variances were statistically smaller for SB than for SG (p < 0.001). The number of vector moduli offsets greater than 5 mm was 2.1 times higher for SG. Compared to other locations, lower lobe lesions moduli were at least 2.3 times higher.

Conclusions

Both systems were accuracy-equivalent but not precision-equivalent systems. Furthermore, the SB system was more precise than the SG one. Despite DIBH, patients with lower lobe lesions had larger offsets than superior lobe ones, mainly in SI.

Management of Motion and Anatomical Variations in Charged Particle Therapy: Past, Present, and Into the Future

The major aim of radiation therapy is to provide curative or palliative treatment to cancerous malignancies while minimizing damage to healthy tissues. Charged particle radiotherapy utilizing carbon ions or protons is uniquely suited for this task due to its ability to achieve highly conformal dose distributions around the tumor volume. For these treatment modalities, uncertainties in the localization of patient anatomy due to inter- and intra-fractional motion present a heightened risk of undesired dose delivery. A diverse range of mitigation strategies have been developed and clinically implemented in various disease sites to monitor and correct for patient motion, but much work remains. This review provides an overview of current clinical practices for inter and intra-fractional motion management in charged particle therapy, including motion control, current imaging and motion tracking modalities, as well as treatment planning and delivery techniques. We also cover progress to date on emerging technologies including particle-based radiography imaging, novel treatment delivery methods such as tumor tracking and FLASH, and artificial intelligence and discuss their potential impact towards improving or increasing the challenge of motion mitigation in charged particle therapy.

Fiducial markers for stereotactic lung radiation therapy: review of the transthoracic, endovascular and endobronchial approaches

Stereotactic body radiation therapy is an alternative to surgery for early-stage, inoperable peripheral non-small cell lung cancer. As opposed to linear accelerator (linac)-based (e.g. gating) and free-breathing techniques, CyberKnife® with Synchrony® technology allows accurate radiation delivery by means of a real-time respiratory motion tracking system using, in most cases, metal fiducial markers (FMs) placed in the vicinity of the target. The aims of this review are as follows. First, to describe the safety and efficacy of the transthoracic, endovascular and endobronchial FM insertion techniques for peripheral pulmonary lesions (PPLs). Second, to analyse performance in terms of the migration and tracking rates of different FM types. Recent developments in FM tracking for central lesions will also be reviewed. In conclusion, for PPLs, the endobronchial approach provides a low rate of pneumothorax, offers the possibility of concurrent diagnostic sampling for both the PPL and the lymph nodes, and, finally, reduces the intervention time compared to other techniques. In this context, coil-tailed and coil-spring FMs have shown the lowest migration rate with a consequently high tracking rate.

Monitoring Respiratory Motion during VMAT Treatment Delivery Using Ultra-Wideband Radar

The goal of this paper is to evaluate the potential of a low-cost, ultra-wideband radar system for detecting and monitoring respiratory motion during radiation therapy treatment delivery. Radar signals from breathing motion patterns simulated using a respiratory motion phantom were captured during volumetric modulated arc therapy (VMAT) delivery. Gantry motion causes strong interference affecting the quality of the extracted respiration motion signal. We developed an artificial neural network (ANN) model for recovering the breathing motion patterns. Next, automated classification into four classes of breathing amplitudes is performed, including no breathing, breath hold, free breathing and deep inspiration. Breathing motion patterns extracted from the radar signal are in excellent agreement with the reference data recorded by the respiratory motion phantom. The classification accuracy of simulated deep inspiration breath hold breathing was 94% under the worst case interference from gantry motion and linac operation. Ultra-wideband radar systems can achieve accurate breathing rate estimation in real-time during dynamic radiation delivery. This technology serves as a viable alternative to motion detection and respiratory gating systems based on surface detection, and is well-suited to dynamic radiation treatment techniques. Novelties of this work include detection of the breathing signal using radar during strong interference from simultaneous gantry motion, and using ANN to perform adaptive signal processing to recover breathing signal from large interference signals in real time.

Comparison of organs at risk doses between deep inspiration breath-hold and free-breathing techniques during radiotherapy of left-sided breast cancer: A Meta-Analysis

After radiotherapy (RT) of left-sided breast cancer patients, organs at risk (OARs) such as heart, left anterior descending (LAD) coronary artery, and left lung could be affected by radiation dose in the long term. The objective of this study was to perform a comprehensive meta-analysis and determine OARs dose reduction during left-sided breast cancer treatment using different RT modalities combined with deep inspiration breath-hold (DIBH) relative to free-breathing (FB). PubMed, Scopus, EMBASE, ProQuest, Google Scholar, and Cochrane Library electronic databases were used to search for studies until June 6, 2021. Nineteen eligible studies were selected and analyzed using the RevMan 5.3 statistical software package. The pooled weighted mean difference (MD) with their 95% confidence intervals for each of the three OAR mean doses were determined using a random-effects meta-analysis model to assess the dose reductions. From a total of 189 studies, 1 prospective study, 15 retrospective studies, and 3 randomized control trials (RCTs) with an overall of 634 patients were included. Reduction of doses to the heart (weighted MD = -1.79 Gy; 95% CI (-2.28, -1.30); P = 0.00001), LAD (weighted MD = -8.34 Gy; 95% CI (-11.06, -5.61); P = 0.00001), and left-lung (weighted MD = -0.90 Gy; 95% CI (-1.19, -0.61); P = 0.00001) were observed using DIBH combinations relative to FB combination. This study emphasizes that during the treatment of left-sided breast/chest wall (CW) ± supraclavicular (SCV) ± infraclavicular (ICV) ± internal mammary chain (IMC) lymph nodes (LN) ± axillary (Ax)/ cancer patients, different RT modalities combined with DIBH techniques are better options to reduce dose to OARs compared to FB, which benefits to minimize the long-term complications.

Research Progress of Heavy Ion Radiotherapy for Non-Small-Cell Lung Cancer

Non-small-cell lung cancer (NSCLC) has a high incidence and poses a serious threat to human health. However, the treatment outcomes of concurrent chemoradiotherapy for non-small-cell lung cancer are still unsatisfactory, especially for high grade lesions. As a new cancer treatment, heavy ion radiotherapy has shown promising efficacy and safety in the treatment of non-small-cell lung cancer. This article discusses the clinical progress of heavy ion radiotherapy in the treatment of non-small-cell lung cancer mainly from the different cancer stages, the different doses of heavy ion beams, and the patient’s individual factors, and explores the deficiency of heavy ion radiotherapy in the treatment of non-small-cell lung cancer and the directions of future research, in order to provide reference for the wider and better application of heavy ion radiotherapy in the future.

The markerless lung target tracking AAPM Grand Challenge (MATCH) results

PURPOSE

Lung stereotactic ablative body radiotherapy (SABR) is a radiation therapy success story with level 1 evidence demonstrating its efficacy. To provide real-time respiratory motion management for lung SABR, several commercial and preclinical markerless lung target tracking (MLTT) approaches have been developed. However, these approaches have yet to be benchmarked using a common measurement methodology. This knowledge gap motivated the MArkerless lung target Tracking CHallenge (MATCH). The aim was to localize lung targets accurately and precisely in a retrospective in silico study and a prospective experimental study.

METHODS

MATCH was an American Association of Physicists in Medicine sponsored Grand Challenge. Common materials for the in silico and experimental studies were the experiment setup including an anthropomorphic thorax phantom with two targets within the lungs, and a lung SABR planning protocol. The phantom was moved rigidly with patient-measured lung target motion traces, which also acted as ground truth motion. In the retrospective in silico study a volumetric modulated arc therapy treatment was simulated and a dataset consisting of treatment planning data and intra-treatment kilovoltage (kV) and megavoltage (MV) images for four blinded lung motion traces was provided to the participants. The participants used their MLTT approach to localize the moving target based on the dataset. In the experimental study, the participants received the phantom experiment setup and five patient-measured lung motion traces. The participants used their MLTT approach to localize the moving target during an experimental SABR phantom treatment. The challenge was open to any participant, and participants could complete either one or both parts of the challenge. For both the in silico and experimental studies the MLTT results were analyzed and ranked using the prospectively defined metric of the percentage of the tracked target position being within 2 mm of the ground truth.

RESULTS

A total of 30 institutions registered and 15 result submissions were received, four for the in silico study and 11 for the experimental study. The participating MLTT approaches were: Accuray CyberKnife (2), Accuray Radixact (2), BrainLab Vero, C-RAD, and preclinical MLTT (5) on a conventional linear accelerator (Varian TrueBeam). For the in silico study the percentage of the 3D tracking error within 2 mm ranged from 50% to 92%. For the experimental study, the percentage of the 3D tracking error within 2 mm ranged from 39% to 96%.

CONCLUSIONS

A common methodology for measuring the accuracy of MLTT approaches has been developed and used to benchmark preclinical and commercial approaches retrospectively and prospectively. Several MLTT approaches were able to track the target with sub-millimeter accuracy and precision. The study outcome paves the way for broader clinical implementation of MLTT. MATCH is live, with datasets and analysis software being available online at https://www.aapm.org/GrandChallenge/MATCH/ to support future research.

Correlation of Optical Surface Respiratory Motion Signal and Internal Lung and Liver Tumor Motion: A Retrospective Single-Center Observational Study

Purpose: Surface-guided radiation therapy (SGRT) application has limitations. This study aimed to explore the relationship between patient characteristics and their external/internal correlation to qualitatively assess the external/internal correlation in a particular patient. Methods: Liver and lung cancer patients treated with radiotherapy in our institution were retrospectively analyzed. The external/internal correlation were calculated with Spearman correlation coefficient (SCC) and SCC after support vector regression (SVR) fitting (SCC_svr). The relationship between the external/internal correlation and magnitudes of motion of the tumor and external marker (A_i, A_e), tumor volume V_t, patient age, gender, and tumor location were explored. Results: The external/internal motions of liver and lung cancer patients were strongly correlated in the S-I direction, with mean SCC_svr values of 0.913 and 0.813. The correlation coefficients between the external/internal correlations and the patients’ characteristics (A_i, A_e, V_t, and age) were all smaller than 0.5; A_i, A_e and liver tumor volumes were positively correlated with the strength of the external/internal correlation, while lung tumor volumes and patient age were negative. The external/internal correlations in males and females were roughly equal, and the external/internal correlations in patients with peripheral lung cancers were stronger than those in patients with central lung cancers. Conclusion: The external/internal correlation shows great individual differences. The effects of A_i, A_e, V_t, and age are weakly to moderately correlated. Our results suggest the necessity of individualized assessment of patient's external/internal motion correlation prior to the application of SGRT technique for breath motion monitoring.

Respiratory motion management for external radiotherapy treatment

We present the update of the recommendations of the French society of oncological radiotherapy on respiratory motion management for external radiotherapy treatment. Since twenty years and the report 62 of ICRU, motion management during the course of radiotherapy treatment has become an increasingly significant concern, particularly with the development of hypofractionated treatments under stereotactic conditions, using reduced safety margins. This article related orders of motion amplitudes for different organs as well as the definition of the margins in radiotherapy. An updated review of the various movement management strategies is presented as well as main technological solutions enabling them to be implemented: when acquiring anatomical data, during planning and when carrying out treatment. Finally, the management of these moving targets, such as it can be carried out in radiotherapy departments, will be detailed for a few concrete examples of localizations (abdominal, thoracic and hepatic).

The impact of modern radiotherapy on long-term cardiac sequelae in breast cancer survivor: a focus on deep inspiration breath-hold (DIBH) technique

INTRODUCTION

One of the most feared side effects of radiotherapy (RT) in the setting of breast cancer (BC) patients is cardiac toxicity. This side effect can jeopardize the quality of life (QoL) of long-term survivors. The impact of modern techniques of RT such as deep inspiration breath hold (DIBH) have dramatically changed this setting. We report and discuss the results of the literature overview of this paper.

MATERIALS AND METHODS

Literature references were obtained with a PubMed query, hand searching, and clinicaltrials.gov.

RESULTS

We reported and discussed the toxicity of RT and the improvements due to the modern techniques in the setting of BC patients.

CONCLUSIONS

BC patients often have a long life expectancy, thus the RT should aim at limiting toxicities and at the same time maintaining the same high cure rates. Further studies are needed to evaluate the risk-benefit ratio to identify patients at higher risk and to tailor the treatment choices.

Target motion management in breast cancer radiation therapy

Background

Over the last two decades, breast cancer remains the main cause of cancer deaths in women. To treat this type of cancer, radiation therapy (RT) has proved to be efficient. RT for breast cancer is, however, challenged by intrafractional motion caused by respiration. The problem is more severe for the left-sided breast cancer due to the proximity to the heart as an organ-at-risk. While particle therapy results in superior dose characteristics than conventional RT, due to the physics of particle interactions in the body, particle therapy is more sensitive to target motion.

Conclusions

This review highlights current and emerging strategies for the management of intrafractional target motion in breast cancer treatment with an emphasis on particle therapy, as a modern RT technique. There are major challenges associated with transferring real-time motion monitoring technologies from photon to particles beams. Surface imaging would be the dominant imaging modality for real-time intrafractional motion monitoring for breast cancer. The magnetic resonance imaging (MRI) guidance and ultra high dose rate (FLASH)-RT seem to be state-of-the-art approaches to deal with 4D RT for breast cancer.

Effect of abdominal compression on target movement and extension of the external boundary of peripheral lung tumours treated with stereotactic radiotherapy based on four-dimensional computed tomography

BACKGROUND

This study aimed to investigate the effect of abdominal compression on tumour motion and target volume and to determine suitable planning target volume (PTV) margins for patients treated with lung stereotactic body radiotherapy (SBRT) based on four-dimensional computed tomography (4DCT).

METHODS

Twenty-three patients diagnosed to have a peripheral pulmonary tumour were selected and divided into an all lesions group (group A), an upper middle lobe lesions group (group B), and a lower lobe lesions group (group C). Two 4DCT scans were performed in each patient, one with and one without abdominal compression. Cone beam computed tomography (CBCT) was performed before starting treatment. The gross target volumes (GTVs) were delineated and internal gross target volumes (IGTVs) were defined. IGTVs were generated using two methods: (1) the maximum intensity projections (MIPs) based on the 4DCT were reconstructed to form a single volume and defined as the IGTVMIP and (2) GTVs from all 10 phases were combined to form a single volume and defined as the IGTV10. A 5-mm, 4-mm, and 3-mm margin was added in all directions on the IGTVMIP and the volume was constructed as PTVMIP_5mm, PTVMIP_4mm, and PTVMIP_3mm.

RESULTS

There was no significant difference in the amplitude of tumour motion in the left-right, anterior-posterior, or superior-inferior direction according to whether or not abdominal compression was applied (group A, p = 0.43, 0.27, and 0.29, respectively; group B, p = 0.46, 0.15, and 0.45; group C, p = 0.79, 0.86, and 0.37; Wilcoxon test). However, the median IGTVMIP without abdominal compression was 33.67% higher than that with compression (p = 0.00), and the median IGTV10 without compression was 16.08% higher than that with compression (p = 0.00). The median proportion of the degree of inclusion of the IGTVCBCT in PTVMIP_5mm, PTVMIP_4mm, and PTVMIP_3mm ≥ 95% was 100%, 100%, and 83.33%, respectively.

CONCLUSIONS

Abdominal compression was useful for reducing the size of the IGTVMIP and IGTV10 and for decreasing the PTV margins based on 4DCT. In IGTVMIP with abdominal compression, adding a 4-mm margin to account for respiration is feasible in SBRT based on 4DCT.

A prospective trial demonstrating the benefit of personalized selection of breath-hold technique for upper-abdominal radiotherapy using the Active Breathing Co-ordinator (ABC)

BACKGROUND

For upper abdominal (UA) tumors, our institutional-standard motion reduction method is Expiration Breath Hold (EBH), using Active Breathing Coordinator (ABC)^TM. However, an individual patient's breath-hold (BH) reproducibility (R_BH) may be improved in Deep Inspiration or Inspiration Breath-Hold (DIBH or IBH). This trial compared the tumor position R_BH, stability (S_BH), and breath-hold time (T_BH) of three BH methods, using ABC, to personalize the selection of technique, by employing a pre-planning screening assessment.

METHODS

Patients planned for UA radiotherapy (kidney, pancreas, liver, or adrenal gland), were invited to participate in this prospective trial. Active Breathing Coordinator (ABC)^TM education was conducted, then participants attempted EBH, DIBH and IBH, in randomized order. During five consecutive BH's for each method, kV fluoroscopy images of the diaphragm were acquired. The BH technique selection was personalized according to a decision matrix. The EBH and the personalized technique cohort mean R_BH and S_BH of were analyzed.

RESULTS

Between May 2019 and March 2020, 19 participants were recruited. Median age of participants was 68 years (range 32-81). Tumor sites included kidney (n=1), adrenal gland (n=5) and liver (n=14). One participant was excluded due to poor BH compliance, leaving 270 images from 18 participants for analysis. Mean T_BH was 22.1, 23.9 & 24.2 seconds for EBH, DIBH and IBH respectively. Screening selected EBH for 44% (n=8), IBH for 39% (n=7) and DIBH for 17% (n=3) of participants. The mean R_BH was superior at 0.92mm (0.79mm SD) for the personalized technique, compared to EBH of 1.79mm (1.49mm SD) (p=0.016). Pre-planned subset analysis of participants whose personalized technique was not EBH showed improved mean R_BH of 0.63mm (0.29mm SD) compared to their EBH R_BH of 2.2mm (1.7mm SD) (p=0.011).

CONCLUSIONS

In 56% of participants, DIBH or IBH demonstrated superior R_BH compared to EBH Personalized BH screening can inform selection of an ABC BH method which provides optimal R_BH with improved T_BH for an individual's planning and treatment course.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR): XXX (withheld - blinded manuscript).

Improvements in beam's eye view fiducial tracking using a novel multilayer imager

Purpose.Electronic portal image devices (EPIDs) have been investigated previously for beams-eye view (BEV) applications such as tumor tracking but are limited by low contrast-to-noise ratio and detective quantum efficiency. A novel multilayer imager (MLI), consisting of four stacked flat-panels was used to measure improvements in fiducial tracking during liver stereotactic body radiation therapy (SBRT) procedures compared to a single layer EPID.Methods.The prototype MLI was installed on a clinical TrueBeam linac in place of the conventional DMI single-layer EPID. The panel was extended during volumetric modulated arc therapy SBRT treatments in order to passively acquire data during therapy. Images were acquired for six patients receiving SBRT to liver metastases over two fractions each, one with the MLI using all 4 layers and one with the MLI using the top layer only, representing a standard EPID. The acquired frames were processed by a previously published tracking algorithm modified to identify implanted radiopaque fiducials. Truth data was determined using respiratory traces combined with partial manual tracking. Results for 4- and 1-layer mode were compared against truth data for tracking accuracy and efficiency. Tracking and noise improvements as a function of gantry angle were determined.Results. Tracking efficiency with 4-layers improved to 82.8% versus 58.4% for the 1-layer mode, a relative improvement of 41.7%. Fiducial tracking with 1-layer returned a root mean square error (RMSE) of 2.1 mm compared to 4-layer RMSE of 1.5 mm, a statistically significant (p < 0.001) improvement of 0.6 mm. The reduction in noise correlated with an increase in successfully tracked frames (r = 0.913) and with increased tracking accuracy (0.927).Conclusion. Increases in MV photon detection efficiency by utilization of a MLI results in improved fiducial tracking for liver SBRT treatments. Future clinical applications utilizing BEV imaging may be enhanced by including similar noise reduction strategies.

Motion compensation combining with local low rank regularization for low dose dynamic CT myocardial perfusion reconstruction

Dynamic CT myocardial perfusion imaging (DCT-MPI) is a reliable examination tool for the assessment of myocardium and vascular, while its special scan protocol may result in excessive radiation exposure to patients and inevitable inter-frame motion. Lowering the tube current is a simple way to reduce radiation exposure. However, low mAs will certainly cause severe image noise, thus may further impact the accuracy of functional hemodynamic parameters, which are used for the assessment of blood supply. In this work, we present a novel scheme applying motion compensation and local low rank regularization (MC-LLR) for obtaining high quality motion compensated DCT-MPI images. Specifically, motion compensation by using robust data decomposition registration (RDDR) was introduced. Robust principal component analysis coupled with optical flow-based registration algorithm were used in RDDR. Then, the local low rank constraint on the motion compensated time series images was applied for the DCT-MPI reconstruction. One healthy mini pig and two patient datasets were used to evaluate the proposed MC-LLR algorithm. Results show that the present method achieved satisfactory image quality with higher CNRs, smaller rRMSEs, and more accurate hemodynamic parameter maps.

First-in-human imaging using a MR-compatible e4D ultrasound probe for motion management of radiotherapy

PURPOSE

Respiration-induced tumor or organ positional changes can impact the accuracy of external beam radiotherapy. Motion management strategies are used to account for these changes during treatment. The authors report on the development, testing, and first-in-human evaluation of an electronic 4D (e4D) MR-compatible ultrasound probe that was designed for hands-free operation in a MR and linear accelerator (LINAC) environment.

METHODS

Ultrasound components were evaluated for MR compatibility. Electromagnetic interference (EMI) shielding was used to enclose the entire probe and a factory-fabricated cable shielded with copper braids was integrated into the probe. A series of simultaneous ultrasound and MR scans were acquired and analyzed in five healthy volunteers.

RESULTS

The ultrasound probe led to minor susceptibility artifacts in the MR images immediately proximal to the ultrasound probe at a depth of <10 mm. Ultrasound and MR-based motion traces that were derived by tracking the salient motion of endogenous target structures in the superior-inferior (SI) direction demonstrated good concordance (Pearson correlation coefficients of 0.95-0.98) between the ultrasound and MRI datasets.

CONCLUSION

We have demonstrated that our hands-free, e4D probe can acquire ultrasound images during a MR acquisition at frame rates of approximately 4 frames per second (fps) without impacting either the MR or ultrasound image quality. This use of this technology for interventional procedures (e.g. biopsies and drug delivery) and motion compensation during imaging are also being explored.

AAPM Task Group 198 Report: An implementation guide for TG 142 quality assurance of medical accelerators

The charges on this task group (TG) were as follows: (a) provide specific procedural guidelines for performing the tests recommended in TG 142; (b) provide estimate of the range of time, appropriate personnel, and qualifications necessary to complete the tests in TG 142; and (c) provide sample daily, weekly, monthly, or annual quality assurance (QA) forms. Many of the guidelines in this report are drawn from the literature and are included in the references. When literature was not available, specific test methods reflect the experiences of the TG members (e.g., a test method for door interlock is self-evident with no literature necessary). In other cases, the technology is so new that no literature for test methods was available. Given broad clinical adaptation of volumetric modulated arc therapy (VMAT), which is not a specific topic of TG 142, several tests and criteria specific to VMAT were added.

Investigation of interfractional variation in lung tumor position under expiratory-phase breath hold using cone-beam computed tomography in stereotactic body radiation therapy

PURPOSE

We investigated the interfractional variation in the tumor position during lung stereotactic body radiotherapy (SBRT) under expiratory-phase breath hold (BH) using cone-beam computed tomography (CBCT).

METHODS

A total of 79 patients with lung cancer were treated with lung SBRT, wherein the Abches system under expiratory-phase BH was used to study interfractional variation. The tumors were located in the upper lobe in 31 cases, in the middle lobe in 11 cases, and in the lower lobe in 37 cases. Planning CTs were scanned under expiratory-phase BH with the Abches system. The 3-degrees-of-freedom (DOF) tumor-based setup using CBCT images under expiratory-phase BH was performed after a 6-DOF bony vertebrae-based setup using an ExacTrac X-ray system. Interfractional variation in the lung tumor position was defined as the difference in the position of the lung tumor relative to the bone anatomy in the left-right (LR), antero-posterior (AP), and craniocaudal (CC) directions represented as absolute values.

RESULTS

The interfractional variation in the lung tumor position was very similar in all the lung regions, and its mean ± standard deviation values in all patients were 1.0 ± 1.1, 1.6 ± 1.9, and 1.6 ± 1.9 mm in the LR, AP, and CC directions, respectively. Further, 99.1%, 92.4%, and 92.7% of all the fractions for the interfractional tumor positional variation in the LR, AP, and CC directions were less than 5 mm, respectively.

CONCLUSION

The interfractional variation in the tumor position was small for lung cancer patients treated with the Abches system under expiratory-phase BH.

Enhanced Deep-Inspiration Breath Hold Superior to High-Frequency Percussive Ventilation for Respiratory Motion Mitigation: A Physiology-Driven, MRI-Guided Assessment Toward Optimized Lung Cancer Treatment With Proton Therapy

Background: To safely treat lung tumors using particle radiation therapy (PRT), motion-mitigation strategies are of critical importance to ensure precise irradiation. Therefore, we compared applicability, effectiveness, reproducibility, and subjects' acceptance of enhanced deep-inspiration breath hold (eDIBH) with high-frequency percussive ventilation (HFPV) by MRI assessment within 1 month.

Methods: Twenty-one healthy subjects (12 males/9 females; age: 49.5 ± 5.8 years; BMI: 24.7 ± 3.3 kg/m⁻²) performed two 1.5 T MRI scans in four visits at weekly intervals under eDIBH and HFPV conditions, accompanied by daily, home-based breath-hold training and spirometric assessments over a 3-week period. eDIBH consisted of 8-min 100% O₂ breathing (3 min resting ventilation, 5 min controlled hyperventilation) prior to breath hold. HFPV was set at 200–250 pulses min⁻¹ and 0.8–1.2 bar. Subjects' acceptance and preference were evaluated by questionnaire. To quantify inter- and intrafractional changes, a lung distance metric representing lung topography was computed for 10 reference points: a motion-invariant spinal cord and nine lung structure contours (LSCs: apex, carina, diaphragm, and six vessels as tumor surrogates distributed equally across the lung). To parameterize individual LSC localizability, measures of their spatial variabilities were introduced and lung volumes calculated by automated MRI analysis.

Results: eDIBH increased breath-hold duration by > 100% up to 173 ± 73 s at visit 1, and to 217 ± 67 s after 3 weeks of home-based training at visit 4 (p < 0.001). Measures of vital capacity and lung volume remained constant over the 3-week period. Two vessels in the lower lung segment and the diaphragm yielded a two- to threefold improved positional stability with eDIBH, whereby absolute distance variability was significantly smaller for five LSCs; ≥70% of subjects showed significantly better intrafractional lung motion mitigation under reproducible conditions with eDIBH compared with HFPV with smaller ranges most apparent in the anterior-posterior and cranial-caudal directions. Approximately 80% of subjects preferred eDIBH over HFPV, with “less discomfort” named as most frequent reason.

Conclusions: Both, eDIBH, and HFPV were well-tolerated. eDIBH duration was long enough to allow for potential PRT. Variability in lung volume was smaller and position of lung structures more precise with eDIBH. Subjects preferred eDIBH over HFPV. Thus, eDIBH is a very promising tool for lung tumor therapy with PRT, and further investigation of its applicability in patients is warranted.

Gated Radiotherapy Development and its Expansion

One of the most important challenges in treatment of patients with cancerous tumors of chest and abdominal areas is organ movement. The delivery of treatment radiation doses to tumor tissue is a challenging matter while protecting healthy and radio sensitive tissues. Since the movement of organs due to respiration causes a discrepancy in the middle of planned and delivered dose distributions. The moderation in the fatalistic effect of intra-fractional target travel on the radiation therapy correctness is necessary for cutting-edge methods of motion remote monitoring and cancerous growth irradiancy. Tracking respiratory milling and implementation of breath-hold techniques by respiratory gating systems have been used for compensation of respiratory motion negative effects. Therefore, these systems help us to deliver precise treatments and also protect healthy and critical organs. It seems aspiration should be kept under observation all over treatment period employing tracking seed markers (e.g. fiducials), skin surface scanners (e.g. camera and laser monitoring systems) and aspiration detectors (e.g. spirometers). However, these systems are not readily available for most radiotherapy centers around the word. It is believed that providing and expanding the required equipment, gated radiotherapy will be a routine technique for treatment of chest and abdominal tumors in all clinical radiotherapy centers in the world by considering benefits of respiratory gating techniques in increasing efficiency of patient treatment in the near future. This review explains the different technologies and systems as well as some strategies available for motion management in radiotherapy centers.

Clinical Implementation and Initial Experience of Real-Time Motion Tracking With Jaws and Multileaf Collimator During Helical Tomotherapy Delivery

PURPOSE

This work reports the clinical implementation of a real-time motion tracking and correction system using dynamic multileaf collimator and jaws during helical tomotherapy delivery (Synchrony on Radixact; Accuray, Inc).

METHODS AND MATERIALS

The first clinical Synchrony on Radixact system was recently installed and tested at our institution. Various clinical workflows, including fiducial implantation, computed tomography simulation, treatment planning, delivery quality assurance, treatment simulation, and delivery, for both fiducial-free and fiducial-based motion tracking methods were developed. Treatment planning and delivery data from initial patients, including dosimetric benefits, real-time target detection, model building, motion tracking accuracy, delivery smoothness, and extra dose from real-time radiographic imaging, were analyzed.

RESULTS

The Synchrony on Radixact system was tested to be within its performance specifications and has been used to treat 10 lung (fiducial-free) and 5 prostate (fiducial-based) patients with cancer so far in our clinic. The success of these treatments, especially for fiducial-free tracking, depends on multiple factors, including careful selection of the patient, appropriate setting of system parameters, appropriate positioning of the patient and skin markers, and use of treatment simulation. For the lung tumor cases, difficulties in model building, due primarily to the changes of target detectability or respiration patterns, were observed, which led to important system upgrades, including the addition of a treatment delivery simulation capability. Motion tracking metrics for all treated patients were within specifications, for example, (1) delivery quality assurance passing rates >95%; (2) extra dose from radiograph <0.5% of the prescription dose; and (3) average Potential Diff, measured Δ, and Rigid Body were within 6.5, 2.9, and 3.9 mm, respectively.

CONCLUSIONS

Practical workflows for the use of the first clinical motion tracking and correction system in helical tomotherapy delivery have been developed, and the system has now been successfully implemented in our clinic for treating patients with lung and prostate cancer.

Impact of breath-hold level on positional error aligned by stent/Lipiodol in Hepatobiliary radiotherapy with breath-hold respiratory control

Background

Respiratory motion management with breath hold for patients with hepatobiliary cancers remain a challenge in the precise positioning for radiotherapy. We compared different image-guided alignment markers for estimating positional errors, and investigated the factors associated with positional errors under breath-hold control.

Methods

Spirometric motion management system (SDX) for breath holds was used in 44 patients with hepatobiliary tumor. Among them, 28 patients had a stent or embolized materials (lipiodol) as alignment markers. Cone-beam computed tomography (CBCT) and kV-orthogonal images were compared for accuracy between different alignment references. Breath-hold level (BHL) was practiced, and BHL variation (ΔBHL) was defined as the standard deviation in differences between actual BHLs and baseline BHL. Mean BHL, ΔBHL, and body-related factors were analyzed for the association with positional errors.

Results

Using the reference CBCT, the correlations of positional errors were significantly higher in those with stent/lipiodol than when the vertebral bone was used for alignment in three dimensions. Patients with mean BHL > 1.4 L were significantly taller (167.6 cm vs. 161.6 cm, p = 0.03) and heavier (67.1 kg vs. 57.4 kg, p = 0.02), and had different positional error in the craniocaudal direction (− 0.26 cm [caudally] vs. + 0.09 cm [cranially], p = 0.01) than those with mean BHL < 1.4 L. Positional errors were similar for patients with ΔBHL< 0.03 L and > 0.03 L.

Conclusion

Under rigorous breath-hold respiratory control, BHL correlated with body weight and height. With more accurate alignment reference by stent/lipiodol, actual BHL but not breath-hold variation was associated with craniocaudal positional errors.

Quantification of Intrafraction and Interfraction Tumor Motion Amplitude and Prediction Error for Different Liver Tumor Trajectories in Cyberknife Synchrony Tracking

PURPOSE

To research the fiducial-based, real-time tracking intrafraction (during the fraction [intra-]) and interfraction (between fractions [inter-]) tumor respiration amplitude, motion trajectory, and prediction error and quantify their relationships for different types of motion trajectories during Cyberknife-based stereotactic ablation radiotherapy.

METHODS AND MATERIALS

Twelve patients with liver tumors were treated using a Cyberknife system, and 58 fractions were involved in this study. Real-time target motion tracking data were extracted and transformed from the robot coordinate system into the patient coordinate system by the rotation matrix. Only the time sessions of the beam on were studied according to the data information generated from the Cyberknife motion tracking system. The motion correlation model between the external marker signal and internal fiducial position was built to present the type of motion trajectory.

RESULTS

Using the correlation model as a function of external marker signal and internal fiducial position, we knew 4 motion trajectories mainly existed for liver cancer patients as follows: perfect linearity (group I), simple linearity (group II), hysteresis (group III), and area respiratory (group IV) patterns. More than half of the patients had a linear breathing trajectory. Analyzing all patients together, the intra-amplitudes were slightly less than those of the inter-amplitudes. The amplitude from large to small was in the superior-inferior, left-right and anterior-posterior directions, regardless of inter- and intra-amplitudes. Then, patients with a larger peak-to-peak have a larger standard deviation of amplitude and a larger amplitude in all fractions/sessions. The prediction errors of the linear motion trajectory were generally less than 1 mm. The prediction errors of the regular hysteresis breathing model were smaller than those of the irregular hysteresis model. Scattered breathing would result in a larger tracking error, such as the area respiratory trajectory. It was logical that prediction errors were larger for patients who showed much variation in their breathing amplitude.

CONCLUSIONS

This paper showed that the liver motion trajectory model included perfect linearity, sample linearity, hysteresis, and area. The linear motion trajectory presented the minimum tracking error and the best stability, and the hysteresis and area trajectory were the worst. Therefore, breathing management, including respiration training, control, and evaluation of motion trajectory in all directions, was significantly necessary during liver SABR treatment.

Does Motion Management Technique for Lung SBRT Influence Local Control? A Single Institutional Experience Comparing Abdominal Compression to Breath-Hold Technique

PURPOSE

Abdominal compression (COMP) and breath-hold with an active breathing coordinator (ABC) device are 2 different respiratory motion management techniques used in lung stereotactic body radiation therapy (SBRT) practice. We compared local failure (LF) results for COMP versus ABC.

METHODS AND MATERIALS

We surveyed our institutional review board-approved prospective registry for patients who were treated with SBRT for either a primary lung cancer (PRIME) or an oligometastatic (OLIGO) diagnosis with a minimum of 6 months' follow-up to determine their rates of local failure by motion management modality.

RESULTS

From October 2003 to July 2014, 873 patients with 931 lesions were treated. Patient characteristics included: 455 (52.1%) female; median age of 73 years (range, 37-97); median Karnofsky performance status (KPS) of 80 (range, 40-100); and median BMI of 26.2 (range, 12.1-56.3). Tumor characteristics included: median tumor size of 2.2 cm (range, 0.7-10.0); median maximum standardized uptake value from positron emission tomography PET SUVmax of 7.5 (range, 0.8-59); 234 (25.4%) were central lesions; 830 (89.2%) lesions were PRIME; and 101 (10.8%) were OLIGO. Median follow-up and SBRT dose were 16.4 months and 50 G in 5 fractions, respectively. Overall crude rate of LF was 9.9%. Use of ABC was not associated with increased LF compared with COMP: hazard ratio (HR) = 1.043 (95% CI 0.48-2.29; P = .92). Three-year actuarial rates of LF for ABC versus COMP were 13.8% and 16.5%, respectively. After stratifying by OLIGO/PRIME, neither ABC nor COMP was significantly associated with LF. Central location may be associated with LF with ABC (HR = 2.087, P = .066). On univariate analysis, BMI, tumor size, PET SUV max and central location were associated with failure, with size the most significant.

CONCLUSIONS

LF rates after lung SBRT were not influenced by form of motion control overall or when stratified by tumor type. Further study on LF rates for central tumors where ABC is used is warranted.

Couch and multileaf collimator tracking: A clinical feasibility study for pancreas and liver treatment

PURPOSE

Real-time tumor tracking through active correction by the multileaf collimator or treatment couch offers a promising strategy to mitigate delivery uncertainty due to intrafractional tumor motion. This study evaluated the performance of MLC and couch tracking using the prototype iTools Tracking system in TrueBeam Developer Mode and the application for abdominal cancer treatments.

METHODS

Experiments were carried out using a phantom with embedded Calypso transponders and a motion simulation platform. Geometric evaluations were performed using a circular conformal field with sinusoidal traces and pancreatic tumor motion traces. Geometric tracking accuracy was retrospectively calculated by comparing the compensational MLC or couch motion extracted from machine log files to the target motion reconstructed from real-time MV and kV images. Dosimetric tracking accuracy was measured with radiochromic films using clinical abdominal VMAT plans and pancreatic tumor traces.

RESULTS

Geometrically, the root-mean-square errors for MLC tracking were 0.5 and 1.8 mm parallel and perpendicular to leaf travel direction, respectively. Couch tracking, in contrast, showed an average of 0.8 mm or less geometric error in all directions. Dosimetrically, both MLC and couch tracking reduced motion-induced local dose errors compared to no tracking. Evaluated with five pancreatic tumor motion traces, the average 2%/2 mm global gamma pass rate of eight clinical abdominal VMAT plans was 67.4% (range: 26.4%-92.7%) without tracking, which was improved to 86.0% (range: 67.9%-95.6%) with MLC tracking, and 98.1% (range: 94.9%-100.0%) with couch tracking. In 16 out of 40 deliveries with different plans and motion traces, MLC tracking did not achieve clinically acceptable dosimetric accuracy with 3%/3mm gamma pass rate below 95%.

CONCLUSIONS

This study demonstrated the capability of MLC and couch tracking to reduce motion-induced dose errors in abdominal cases using a prototype tracking system. Clinically significant dose errors were observed with MLC tracking for certain plans which could be attributed to the inferior MLC tracking accuracy in the direction perpendicular to leaf travel, as well as the interplay between motion tracking and plan delivery for highly modulated plans. Couch tracking outperformed MLC tracking with consistently high dosimetric accuracy in all plans evaluated, indicating its clinical potential in the treatment of abdominal cancers.

Direct tumor visual feedback during free breathing in 0.35T MRgRT

To present a tumor motion control system during free breathing using direct tumor visual feedback to patients in 0.35 T magnetic resonance-guided radiotherapy (MRgRT). We present direct tumor visualization to patients by projecting real-time cine MR images on an MR-compatible display system inside a 0.35 T MRgRT bore. The direct tumor visualization included anatomical images with a target contour and an auto-segmented gating contour. In addition, a beam-status sign was added for patient guidance. The feasibility was investigated with a six-patient clinical evaluation of the system in terms of tumor motion range and beam-on time. Seven patients without visual guidance were used for comparison. Positions of the tumor and the auto-segmented gating contour from the cine MR images were used in probability analysis to evaluate tumor motion control. In addition, beam-on time was recorded to assess the efficacy of the visual feedback system. The direct tumor visualization system was developed and implemented in our clinic. The target contour extended 3 mm outside of the gating contour for 33.6 ± 24.9% of the time without visual guidance, and 37.2 ± 26.4% of the time with visual guidance. The average maximum motion outside of the gating contour was 14.4 ± 11.1 mm without and 13.0 ± 7.9 mm with visual guidance. Beam-on time as a percentage was 43.9 ± 15.3% without visual guidance, and 48.0 ± 21.2% with visual guidance, but was not significantly different (P = 0.34). We demonstrated the clinical feasibility and potential benefits of presenting direct tumor visual feedback to patients in MRgRT. The visual feedback allows patients to visualize and attempt to minimize tumor motion in free breathing. The proposed system and associated clinical workflow can be easily adapted for any type of MRgRT.

Is 5 mm breath-hold window (BHW) sufficient to treat carcinoma left breast patients post-conservative surgery: a comparative study using forward intensity-modulated radiotherapy (FIMRT) and volumetric modulated arc therapy (VMAT)

Purpose:

The purpose of the study was to evaluate the impact of changes in breathing pattern inside the breath-hold window (BHW) during deep inspiration breath hold treatment for carcinoma left breast patients post-conservative surgery.

Methods:

Ten patients of carcinoma left breast post-conservative surgery were prospectively selected. Three sets of CT plain images were acquired, one with 5 mm deep inspiration BHW (DIBHR) and the other one with 1 mm BHW matching the lower threshold (DIBHL) and the third one with 1 mm BHW matching the upper threshold (DIBHH) as DIBHR. For all patients, forward intensity-modulated radiotherapy (FIMRT) and volumetric modulated arc therapy (VMAT) plans were generated in the 5 mm BHW CT series and the same plan being copy and pasted in other series. Target volume doses and critical structure doses were tabulated.

Results:

Planning target volume coverage was adequate and no significant differences were found in any CT series. Significant differences noted in average left lung V5%, V10% and V18% doses between DIBHR versus DIBHH (p values = 0·0461, 0·0283 and 0·0213, respectively) and DIBHL versus DIBHH (p values = 0·0434, 0·0484 and 0·0334, respectively) for FIMRT plans and V18% doses in DIBHR versus DIBHH (p = 0·0067) in VMAT. No differences in heart and apex of heart doses were found. Left anterior descending artery (LAD) mean doses were significant in DIBHL versus DIBHR, DIBHR versus DIBHH and DIBHL versus DIBHH (p = 0·0012, 0·0444 and 0·0048, respectively) series for FIMRT plans and DIBHR versus DIBHH and DIBHL versus DIBHH (p = 0·0341, 0·0001) for VMAT plans.

Finding:

The changes in the breathing pattern inside DIBH window level cause some variation in LAD doses and no other significant differences in any parameters noted, so care should be taken while treating patients with preexisting cardiac conditions.

New method for measurement of chest surface motion in lung cancer patients: Quantification using a technique of deformable image registration

The purpose of this study was to measure the motion of the chest surface during breath-holding treatment for lung cancer using deformable image registration (DIR). Forty non-small-cell lung cancer patients treated with breath-holding stereotactic body radiation therapy were retrospectively examined. First, intensity-based DIR between 2 breath-holding computed tomography (CT) images was performed. Subsequently, deformation vector field (DVF) for all dimensions (left-right, anterior-posterior, and superior-inferior) was calculated from the result. For the analysis of chest surface, the DVF value of the only chest surface area was extracted after the chest surface was divided into 12 regions of interest (ROI) based on anatomy. Additionally, for the analysis of the correlation with the internal tumor motion, the median value of DVF for each surface ROI and the motion of the center of gravity of the tumor volume were used. It was possible to calculate the motion of chest surface without any outliers for all patients. For the average of 12 surface ROIs, the motion of 3D chest surface was within 2 mm (30 cases), 3 mm (8 cases), and 4 mm (2 cases). There was no correlation between the motion of the chest surface and that of the tumor for all 12 surface ROIs. We proposed a technique to evaluate the surface motion using DIR between multiple CT images. It could be a useful tool to calculate the motion of chest surface.

A modern review of the uncertainties in volumetric imaging of respiratory-induced target motion in lung radiotherapy

Radiotherapy has become a critical component for the treatment of all stages and types of lung cancer, often times being the primary gateway to a cure. However, given that radiation can cause harmful side effects depending on how much surrounding healthy tissue is exposed, treatment of the lung can be particularly challenging due to the presence of moving targets. Careful implementation of every step in the radiotherapy process is absolutely integral for attaining optimal clinical outcomes. With the advent and now widespread use of stereotactic body radiation therapy (SBRT), where extremely large doses are delivered, accurate, and precise dose targeting is especially vital to achieve an optimal risk to benefit ratio. This has largely become possible due to the rapid development of image-guided technology. Although imaging is critical to the success of radiotherapy, it can often be plagued with uncertainties due to respiratory-induced target motion. There has and continues to be an immense research effort aimed at acknowledging and addressing these uncertainties to further our abilities to more precisely target radiation treatment. Thus, the goal of this article is to provide a detailed review of the prevailing uncertainties that remain to be investigated across the different imaging modalities, as well as to highlight the more modern solutions to imaging motion and their role in addressing the current challenges.

Provision of a consistent national approach to radiation therapy workforce protection measures in Australia during the COVID-19 pandemic

Healthcare workers are at the frontline managing COVID-19 patients with transmission of the COVID-19 virus to healthcare workers evident in many Australian states. Minimisation of this spread is vital to protecting the healthcare workforce with individual organisations detailing best practice for infection and control. However, interpretation and implementation of infection control guidelines is varied across Australian Radiation Therapy Departments, highlighting inconsistencies. Strong leadership, quality communication and clear direction is required during this crisis to ensure that radiation therapists receive all necessary support and resources required to maintain safety and well-being during the COVID-19 pandemic.