Optimization of an Image-guided Radiation Therapy Protocol for Advanced Stage Lung Cancer

Abstract

Image-guided radiation therapy (IGRT) provides accurate and precise tumour targeting. To ensure adequate coverage in IGRT, a planning target volume (PTV) margin is added around the target to account for treatment uncertainties. Treatment plans are designed to deliver a high percentage of the prescription dose to the PTV; thus, portions of healthy tissue are also subjected to high radiation dose. IGRT employs dedicated devices that enable visual assessment of some treatment uncertainties, such as variations in patient set-up. Safe and effective IGRT delivery requires adherence to disease site-specific protocols that describe process details such as imaging technique, alignment method, and corrective action levels. Protocol design is challenging since its effect on treatment accuracy is currently unknown. This thesis aims to understand the interplay between lung IGRT protocol parameters by developing a framework that quantifies geometrical accuracy. Deformable image registration was used to account for changes in target shape and size throughout treatment. Sufficient accuracy was considered when at least 99% of the target surface fell within the PTV. This analysis revealed that the clinical 10 mm PTV margin can be safely reduced by at least 2 mm in each direction. Evaluation of IGRT accuracy was extended to spinal cord alignment. Simulations were carried out with various matching strategies to correct for set-up error, including rotational off-sets. Inappropriate combinations of matching strategies and safety margins resulted in sub-optimal geometrical coverage. Various lung IGRT protocol options were recommended to optimize accuracy and workflow efficiency. For example, an 8 mm PTV margin can be used with spinal cord alignment, a 4 mm cord margin, and up to 5° of rotational error. A more aggressive protocol involved a 6 mm PTV margin with direct target alignment, a 5 mm cord margin, and a 4° rotational tolerance.