Image–Guided Radiation Therapy for Non–small Cell Lung Cancer

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Image–Guided Radiation Therapy for Non–small Cell Lung Cancer Joe Y. Chang, MD, PhD, Lei Dong, PhD, Helen Liu, PhD, George Starkschall, PhD, Peter Balter, PhD, Radhe Mohan, PhD, Zhongxing Liao, MD, James D. Cox, MD, Ritsuko Komaki, MD Journal of Thoracic Oncology Volume 3, Issue 2, Pages 177-186 (February 2008) DOI: 10.1097/JTO.0b013e3181622bdd Copyright © 2008 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 1 Positron emission tomography–computed tomography (PET-CT)-guided target volume delineation. A, A PET-CT image indicates right hilar lymph node involvement that was not clearly evident on the CT image alone. B, A PET/CT image differentiates gross tumor from collapsed lung tissue. C, False-positive PET-CT scans can be caused by inflammation caused by infection or postradiation pneumonitis. The right upper lobe lesion was squamous cell carcinoma; however, the left upper lobe lesion was shown on biopsy to be inflammation. Journal of Thoracic Oncology 2008 3, 177-186DOI: (10.1097/JTO.0b013e3181622bdd) Copyright © 2008 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 2 A, 4-D CT image to take motion into consideration. The CT images are acquired with the patient in a single couch position for a period of time slightly longer than a single respiratory cycle; then the couch is indexed a distance equal to the detector width. Images are fused based on the phase of the respiratory cycle and 4-D images generated. B, Graphic representation of the International Commission on Radiation Units (ICRU) definitions of gross tumor volume (GTV), clinical tumor volume (CTV), internal target volume (ITV), and planning target volume (PTV). Arrows indicate CTV motion. C, Graphic representation of tumor motion during the breathing cycle based on 4-D CT images. IGTV, internal gross tumor volume; T50, end of expiration (the ideal phase for respiratory-gated therapy); T0, end of inspiration (the ideal phase for breath-hold radiotherapy). Breath should be evaluated and tumor motion considered by using 4-D CT. If the tumor moves more than 1 cm and the patient can tolerate the breath-hold technique, the tumor should be treated with active breath-hold radiotherapy at the end of inspiration (T0 phase). If the patient cannot tolerate breath-hold but can breathe regularly, the tumor should be treated with gated radiotherapy at the end of expiration (T50). However, if the patient can neither hold their breath nor breathe regularly, an ITV approach should be used, preferably the approach that uses maximal intensity projection image coverage of the envelope of the tumor motion path. Journal of Thoracic Oncology 2008 3, 177-186DOI: (10.1097/JTO.0b013e3181622bdd) Copyright © 2008 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 3 On-board images and adapted radiotherapy. A, kV cone-beam CT (Varian Trilogy). B, CT on rails. C, Adapted radiotherapy based on three-dimensional images using on-board CT. The patient was aligned based on a bony landmark. The target coverage was verified in daily CT images using the simulation CT images as reference. Appropriate adjustments were made before each treatment. Journal of Thoracic Oncology 2008 3, 177-186DOI: (10.1097/JTO.0b013e3181622bdd) Copyright © 2008 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 4 Tomotherapy is an integrated IGRT system combining a linear accelerator with an MVCT image guidance system. Journal of Thoracic Oncology 2008 3, 177-186DOI: (10.1097/JTO.0b013e3181622bdd) Copyright © 2008 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 5 Real-time tracking radiation therapy (RTRT). A, BrainLAB. B, CyberKnife system. Journal of Thoracic Oncology 2008 3, 177-186DOI: (10.1097/JTO.0b013e3181622bdd) Copyright © 2008 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 6 Example of missing the target because of intrafraction tumor motion. An IMRT plan was developed for a stage I NSCLC located in the left lower lobe using conventional free-breath CT simulation with uniform PTV margin. The plan was recalculated in 10 breathing phases obtained using 4-D CT. The inferior portion of the CTV (yellow line) moved outside the prescription dose line (red line, 70 Gy) in phases 1 through 4. Journal of Thoracic Oncology 2008 3, 177-186DOI: (10.1097/JTO.0b013e3181622bdd) Copyright © 2008 International Association for the Study of Lung Cancer Terms and Conditions