To evaluate our mature follow-up data in women who have developed IBTR following conservation surgery and post-operative external radiotherapy retreated by lumpectomy followed by LDR in lieu of salvage mastectomy. Between 1/1998 and 10/2006, twenty-two patients with TIS or T1 IBTR were offered interstitial LDR following tumor re-excision as an alternative to salvage mastectomy. All patients had an initial lumpectomy followed by standard postoperative external beam radiotherapy [range 5000-6480cGy including boost]. Six recurred as ductal carcinoma in situ, two as infiltrating lobular carcinoma (one with a DCIS component), and fourteen as recurrent invasive carcinoma (four with a DCIS component). The recurrent tumors were excised with final margins of resection free of residual disease per National Surgical Adjuvant Breast and Bowel Project (NSABP) definition. Tumor bed implantation was then carried out with an interstitial technique utilizing 192Iridium with the target volume consisting of the tumor bed plus a minimum 1.0 centimeter clinical margin. With a mean follow up of 67.5 months (range 17-115 months) Twenty-one of twenty-two patients maintained local control at the time of last follow-up or at the time of their death. The single patient who developed a second local recurrence was treated successfully with simple mastectomy. Three patients succumbed to systemic disease at 17 and 24 months after salvage implant therapy. Three patients died from unrelated causes. One patient was lost to follow-up after three years. One patient developed a contralateral breast cancer. Long-term cosmetic results as defined by the Harvard cosmesis scale (13 grade I, 6 grade II, 3 grade III) and the Allegheny General modification (which accounts for the initial cosmetic appearance) the score worsened in only 4 patients. These long-term data suggest that lumpectomy followed by LDR is feasible and may be an acceptable alternative to salvage mastectomy in patients for whom initial breast conservative therapy has failed. The Allegheny General Modification score better represents the long-term cosmetic effects of retreatment.

Purpose: To update the Allegheny General Hospital experience of high-risk Stage 1 non small-cell lung cancer patients treated with sublobar resection and intraoperative (125)I Vicryl mesh brachytherapy.Methods and Materials: Between January 5, 1996 and February 19, 2008, 145 patients with Stage! non small-cell lung cancer who were not lobectomy candidates because of cardiopulmonary compromise underwent sublobar resection and placement of (125)I seeds along the resection line. The (125)I seeds embedded in Vicryl suture were attached with surgical clips to a sheet of Vicryl mesh, inserted over the target area, and prescribed to a 0.5-cm planar margin.Results: The mean target area, total activity, number of seeds implanted, and prescribed total dose was 33.3 cm(2) (range, 18.0-100.8), 20.2 mCi (range, 11.1-29.7), 46 (range, 30-100), and 117 Gy (range, 80-180), respectively. The median length of the surgical stay was 6 days (range, 1-111), with a perioperative mortality rate of 3.4%. At a median follow-up of 38.3 months (range, 1-133), 6 patients had developed local recurrence (4.1%), 9 had developed regional failure (6.2%), and 25 had distant failure (17.2%). On multivariate analysis, no patient- or tumor-specific factors or surgical or dosimetric factors were predictive of local recurrence. The overall median survival was 30.5 months with a 3- and 5-year overall survival rate of 65% and 35%, respectively.Conclusion: (125)I brachytherapy for high-risk, Stage 1 non small-cell lung cancer after sublobar resection is well tolerated and associated with a low local failure rate. (C) 2011 Elsevier Inc.

SPECT provides functional imaging of the liver parenchyma through uptake of radioactive colloid by Kupffer cells in proportion to vascular perfusion. Our goal was to incorporate liver SPECT-CT imaging for SBRT 3-D conformal treatment planning in order to minimize irradiation to volumes of well perfused normal liver parenchyma. Fourteen patients with unresectable metastatic (13) or primary (1) hepatic tumors completed liver SPECT with 99mTc sulfur colloid for treatment planning and have been evaluated for response after > 2 months from completion of SBRT (median 6.8 months, range, = 2.5-13.5 months). Using body surface markers, SPECT images were co-registered with CT using the Leonardo multi-modality workplace software (Siemens, Malvern, PA). Contoured volumes of photogenic SPECT normal liver parenchyma (SPECT-NLV) were incorporated into 3D-conformal treatment planning. CT and SPECT-based dosimetry was compared and predicted normal liver volumes were calculated. PTV included 4D-CT-defined internal target volume (ITV) with an additional 0 to 5 mm margin. The cumulative mean PTV was 285 cm3 (range, 15-1265 cm3). The dose per fraction ranged from 6 Gy to 12 Gy with a mean total SBRT dose of 45 Gy (range, 30-50 Gy) prescribed to the isodose line encompassing the PTV. Megavoltage cone-beam CT was used for image-guidance. In 6 of the 14 patients, there was no detected SPECT-NLV reduction. However, in the remaining 8 patients with chemotherapy induced hepatic injury including one with recent major hepatectomy there was reduction of the SPECT- NLV /CT compared to CT only imaging by a mean of 27% (range, 21-50%). For most of these patients, < 40% of the predicted SPECT-NLV (mean of 26.5%, range, 9.5%-54%) received ≤ 18 Gy (BED = 40 Gy3) by using 3D-conformal treatment planning, dose intensity modulation, and/or reduction of the total dose. Two patients with reduced SPECT-NLV who received ≥ 18 Gy to 41% and 54% of predicted SPECT-NLV respectively developed grade 2 elevation of liver enzymes. Otherwise, no incidence of > grade 1 radiation induced liver disease was observed. Patients with larger tumors who completed palliative SBRT experienced improvement in performance or/and pain control. To date, the overall in-field local control for palliative and definitive SBRT is 93% with no incidence of liver failure. Our data present a novel and simple method of SPECT/CT registration for SBRT 3-D conformal treatment planning. It allows identification and conformal avoidance of functional normal liver parenchyma from high radiation doses thus facilitating safety of liver SBRT in patients with preexisting liver disease.

To compare low dose rate interstitial brachytherapy to high dose rate intracavitary brachytherapy for IBTR re-treated by lumpectomy. Between 1/1998 and 11/2008, 32 patients with TIS to T2 (< 3 cm) breast carcinoma were offered brachytherapy following failed BCT and WBI (range 4500 - 6600 cGy) as an alternative to salvage mastectomy. One additional patient developed an in-field breast cancer following full mantle irradiation (4500 cGy) for Hodgkin's Lymphoma 27 years prior. All tumors were re-excised with negative margins per National Surgical Adjuvant Breast and Bowel Project (NSABP) definition. Following repeat lumpectomy, tumor bed implantation was carried out utilizing a low dose rate (LDR) interstitial technique (4500 -5530 cGy at 35 - 50 cGy per hour to the tumor bed plus a 1.0 cm margin) in 23 patients. Five patients were treated with high dose rate (HDR) brachytherapy (3400 cGy twice daily at 340 cGy/fx according to NSABP B-39/ RTOG 0413 protocol) using the MammoSite system and five were treated using the Contura multi-lumen system. Maximum skin and rib dosages in the patients treated with the Contura system were additionally compared using the central lumen of the catheter in a multi-dwell idealized delivery against a multi-lumen delivery. Two patients (LDR group) developed grade III acute complications by the Common Terminology Criteria for Adverse Events (v. 3.0). Four patients (HDR group) developed grade I acute complications. With the Contura® system, the mean reduction in maximum skin and rib doses was 12.2% and 13.9% respectively (range: 0- 43.7%) compared to MammoSite. With skin and rib distances of less than 1 cm, the mean dose reductions were 18% and 33.6% respectively. NSABP cosmesis grading scores were: Grade I in 25 patients (including the 10 MammoSite and Contura patients), Grade II in 2 patients, Grade III in 3 patients, and was unavailable for 3 patients. 32 of 33 patients remain free of local failure with a mean follow-up of 24.9 months (range 1 - 90.6 months). Repeat BCT and brachytherapy radiation for IBTR is a feasible process. HDR intracavitary brachytherapy has decreased acute toxicities compared to LDR interstitial brachytherapy. The Contura device provides noticeable skin and rib dose reductions. The long term cosmetic effect of HDR intracavitary compared to LDR interstitial brachytherapy following repeat lumpectomy for IBTR is superior. HDR intracavitary brachytherapy and repeat lumpectomy is a reasonable alternative for the treatment of IBTR.

Adjuvant radiation and hormonal therapy are administered following surgery in patients with hormone receptor positive breast cancer managed by breast conserving therapy. There are limited data about combined morbidity of aromatase inhibitors and concurrent whole breast radiation therapy (WBRT). In this retrospective analysis, we compared radiation toxicity in patients treated with concurrent anastrozole (ANZ) and WBRT (Group 1), women treated sequentially with WBRT followed by hormonal therapy (Group 2) and those who received concurrent tamoxifen (TAM) and WBRT (Group 3). Records of 253 consecutive hormone receptor positive breast cancer patients (clinical stage 0 - IIIA) were reviewed. Both estrogen (ER) and progesterone (PR) receptors were positive in 83% of women; ER only in 13.4%, and PR only in 3.6%. All received conservation breast surgery followed by WBRT at our institution. Fifty-nine patients (Group 1) received concurrent ANZ prior to and during radiotherapy. In 128 patients (Group 2) adjuvant hormonal therapy (ANZ or TAM) was administered after completion of breast irradiation and, 63 women (Group 3), received concurrent TAM and radiation therapy. Sequence of radiation and hormonal therapy was unknown in three patients excluded from this study. Groups were balanced with respect to tumor characteristics. Women who received concurrent ANZ were older than those treated sequentially with hormonal therapy and than those who received concurrent TAM (average age for Group 1, 65 years; Group 2, 57; Group 3, 52; p = < .0001). More patients with concurrent ANZ or TAM received preceding systemic chemotherapy compared to the sequential group (Group 1, 39.0%; Group 2, 23.4%; Group 3, 50.1%; p = .0006). Despite less frequent use of chemotherapy in the sequential group (Group 2), the frequencies of grade 2 radiation dermatitis (23.7%, 20.3%, 28.6% p =.44), grade 3 radiation dermatitis (8.5%, 7.8%, 1.6% p =.19) and, treatment interruptions due to skin reactions (13.6%, 11.7%, 11.1% p = .90) did not differ significantly between treatment groups. Development of skin hyperpigmentation of any grade was similar in each group, and the rates of excellent cosmetic outcome (as scored by the Harvard criteria) were the same. With a median follow up of 21.5 months, no local failures occurred in the concurrent ANZ group, five occurred in the sequential group (median follow up 20 months), and three in the concurrent TAM group (median follow up 33 months). Anastrozole, administered concurrently with WBRT, did not increase acute morbidity when compared to either sequential administration of radiation and hormonal therapy or concurrent tamoxifen and radiation.

During conformal pelvic irradiation for colorectal and anal canal cancer, patients are usually setup in the prone position on a belly board in order to reduce dose to the small bowel (SB). Recently, hypofractionated IMRT has been used as a treatment modality for patients with these malignancies. The objective of this study was to compare radiation-induced SB acute toxicity in supine patients treated with hypofractionated IMRT vs. prone patients treated with standard fractionation 3D-CRT. Twenty-three patients received 5FU-based chemotherapy and concomitant radiotherapy for primary colorectal or anal canal malignancies. Thirteen patients received supine hypofractionated pelvic or pelvic-inguinal IMRT with simultaneous integrated tumor boost to 4,950-5,500 cGy in 22-25 fractions. Ten patients received prone 3D conformal external beam radiotherapy to the whole pelvis, followed by a tumor boost for cumulative doses of 5,040-5,580 cGy in 28-31 fractions. All patients were localized either daily or twice weekly using mega-voltage CBCT. The couch shifts for the supine and prone patients were recorded and compared. Grades of diarrhea were recorded according to NCI CTCAE v3.0, and compared against the volume of SB receiving doses greater than defined levels, from 5 to 55 Gy in 5 Gy steps (V5-V55). The shift distributions for the prone and supine patients did not suggest any difference in terms of setup uncertainty. However, random errors in the order of 7-8 mm, and up to 1.5 cm for some patients, emphasize the need for daily localization for both setups. The average ratio of mean SB V5-V30 values for patients in the supine to prone position was 2.6 (range, 1.4-3.5, p < 0.05). However at higher doses, V40-V55, the average ratio was 1.0 (range, 0.01-2.5). Four prone patients (40%), and 7 supine patients (54%) developed diarrhea of grade 2 or 3 (p = 0.3). No patients experienced diarrhea greater than grade 3. Data show that while the prone position provides better SB volume sparing at low doses (<35 Gy) in 3D-CRT, the supine hypofractionated IMRT approach offers similar volume sparing for doses greater than 40 Gy. The absence of a statistically significant difference in diarrhea incidence suggests that high SB doses (>40 Gy) are linked to acute toxicity, in agreement with recent studies showing V45 as the best predictor. These initial results suggest that hypofractionated IMRT in supine position is a reasonable alternative clinical approach for rectal and anal canal cancer. Due to significant interfractional set-up uncertainty, daily image-guidance is recommended.

Purpose: To compare portal imaging (PI) and mega‐voltage cone‐beam CT (MV‐CBCT) for head and neck (HN) cancer patient localization. Method and Materials: The treatment couch shifts were recorded for 30 HN cancer patients localized weekly using anterior‐posterior and right‐lateral portal images, and for 11 patients localized using MV‐CBCT, either daily (n=4) or twice weekly (n=7). A total of 214 and 184 shifts were obtained for PI and MV‐CBCT, respectively, in the left‐right (LR), superior‐inferior (SI) and anterior‐posterior (AP) directions, along with the magnitude of the 3D shifts. The percentage of shifts that are equal to 0 in any direction, that is no treatment couch correction was applied in that direction, was also compared for the two techniques. Results: The average MV‐CBCT and PI shifts were −0.9±3.9 and 0.0±2.2 mm, respectively, in the LR direction, −0.2±2.4 and −0.1±3.5 mm in the SI direction, −1.0±4.2 and −0.2±2.6 mm in the AP direction. The average 3D shifts were 5.2±3.6 mm and 2.2±4.3 mm for MV‐CBCT and PI, respectively. The proportion of 0 mm shifts for MV‐CBCT and PI was 55% and 88%, respectively, in the LR direction, 71% and 81% in the SI direction, 49% and 90% in the AP direction. Conclusion: The three‐dimensional nature of the MV‐CBCT localization method offers a greater ability to detect small shifts and helps reach a compromise between the 3 translational treatment couch shifts that can be applied and the 12 degrees of freedom corresponding to translational and rotational movements of the head and/or neck, independently. This greater accuracy of MV‐CBCT allows to reduce CTV‐to‐PTV margins, therefore potentially improving the therapeutic ratio. Research partially supported by Siemens Medical Solutions.

Purpose: FDG‐PET imaging is routinely used to diagnose and stage cancer patients. It is also gaining wide acceptance as a tool to assist in tumor delineation in radiotherapy (RT) treatment planning. However, target volume definition is subject to inter‐observer variability. The objective of this study was to evaluate several existing auto‐contouring methods and develop a technique that would reduce inter‐observer variability. Method and Materials: Eighteen rectal and anal cancer patients who had undergone PET‐CT imaging and received RT were retrospectively reviewed. For each patient, a FDG‐PET avid (AVID) region was contoured by an experienced clinician without the use of the CT scan. The AVID volume was compared to volumes derived by the automated methods. Three automated methods were used: a fixed SUV cutoff of 2.5, previously suggested in the literature, a percentage of the maximum SUV (%SUVmax), and an in‐house derived mathematical technique. A 43% threshold was found for %SUVmax using a phantom study with cylinders of known volumes filled with varying concentrations of FDG. The mathematical approach generated 3D volumes using a Confidence Connected Region Growing (CCRG) technique that calculated the mean and standard deviation from pixel intensities contained in a 3D volume grown from a seed pixel. Results: The class solution of using a single value of SUV or a %SUVmax proved limited. These two methods depend on the correct threshold being applied and need to be different for each patient. The resulting volume differences ranged from 1%–129%. The CCRG based volumes were within 8% of the AVID volumes with a range of 1%–23%. Conclusion: Assuming that the same seed pixel is chosen, the CCRG method reduces inter‐observer contouring variability on FDG‐PET images and provides a viable clinical solution by always growing the same volume.Research partially supported by Siemens Medical Solutions.

Purpose/Objective(s)Chemoradiation with dose escalation to the target volume may increase complete pathologic response in patients with rectal or AC cancer. Accurate delineation of GTV is essential in preventing geographic misses during conformal radiotherapy. In this study, the FDG-PET/CT simulation data from patients with DR or AC cancer were evaluated and compared to endorectal ultrasound (ERUS), pelvic CT, colonoscopy, and digital rectal exam (DRE).Materials/MethodsBetween 5/06 and 12/07, 24 DR (T1-4 N0-3 M0-1) and 7 AC (T2-3 N0-3 M0) cancer patients received FDG-PET/CT-based treatment planning for 3D-CRT (n = 14) and IMRT with simultaneous integrated boost (n = 17). The DRE, ERUS, and colonoscopy was performed by the same colorectal surgeon. Interpretation of the pelvic CT for tumor length was performed with and without DRE and colonoscopy information by the same radiologist. The length of the rectal mass on PET/CT was compared between ERUS, CT, DRE, and colonoscopy and correlated with DRE and ERUS.ResultsThe FDG-PET/CT enabled tumor identification and volume measurement in all 31 patients. Tumor length on ERUS, DRE, and colonoscopy was evaluated in 20 (65%), 27 (87%) and 29 (94%) patients, respectively. The CT was inconclusive in 4 patients having DRE and colonoscopy information, tumor was incorrectly localized in 2 patients and could not be identified in 1. The mean length of anorectal cancers was 5.1 cm (95%, CI, 4.2-6.1) by PET/CT, 4 cm (95%, CI, 3.02-4.9) by ERUS, 3.8 cm (95%, CI, 3.3-4.5) by DRE, and 5.2 cm (95%, CI, 4.1-6.4) by colonoscopy. When ERUS, DRE, and colonoscopy results were available for all patients (15), the tumor length by PET/CT correlated best with ERUS (r = 0.82, Pearson correlation coefficient). In addition, PET/CT treatment planning helped to determine nodal disease in 3 patients, metastatic disease in 2, and 5 patients were clinically upstaged.ConclusionsMultiple factors including stenotic lesions, patient discomfort, and rectal scarring adversely affect accuracy of DRE, ERUS, and colonoscopy. Furthermore, DRE, and colonoscopy evaluation of tumor volume is limited to 2-dimensions and CT does not always identify tumor. The FDG-PET/CT has significant impact on both target volume evaluation and staging and may reduce the risk of geographic target misses with conformal radiotherapy. An automated region-growing algorithm for delineation on PET images will be incorporated into our protocol to minimize inter-observer variability errors. Purpose/Objective(s)Chemoradiation with dose escalation to the target volume may increase complete pathologic response in patients with rectal or AC cancer. Accurate delineation of GTV is essential in preventing geographic misses during conformal radiotherapy. In this study, the FDG-PET/CT simulation data from patients with DR or AC cancer were evaluated and compared to endorectal ultrasound (ERUS), pelvic CT, colonoscopy, and digital rectal exam (DRE). Chemoradiation with dose escalation to the target volume may increase complete pathologic response in patients with rectal or AC cancer. Accurate delineation of GTV is essential in preventing geographic misses during conformal radiotherapy. In this study, the FDG-PET/CT simulation data from patients with DR or AC cancer were evaluated and compared to endorectal ultrasound (ERUS), pelvic CT, colonoscopy, and digital rectal exam (DRE). Materials/MethodsBetween 5/06 and 12/07, 24 DR (T1-4 N0-3 M0-1) and 7 AC (T2-3 N0-3 M0) cancer patients received FDG-PET/CT-based treatment planning for 3D-CRT (n = 14) and IMRT with simultaneous integrated boost (n = 17). The DRE, ERUS, and colonoscopy was performed by the same colorectal surgeon. Interpretation of the pelvic CT for tumor length was performed with and without DRE and colonoscopy information by the same radiologist. The length of the rectal mass on PET/CT was compared between ERUS, CT, DRE, and colonoscopy and correlated with DRE and ERUS. Between 5/06 and 12/07, 24 DR (T1-4 N0-3 M0-1) and 7 AC (T2-3 N0-3 M0) cancer patients received FDG-PET/CT-based treatment planning for 3D-CRT (n = 14) and IMRT with simultaneous integrated boost (n = 17). The DRE, ERUS, and colonoscopy was performed by the same colorectal surgeon. Interpretation of the pelvic CT for tumor length was performed with and without DRE and colonoscopy information by the same radiologist. The length of the rectal mass on PET/CT was compared between ERUS, CT, DRE, and colonoscopy and correlated with DRE and ERUS. ResultsThe FDG-PET/CT enabled tumor identification and volume measurement in all 31 patients. Tumor length on ERUS, DRE, and colonoscopy was evaluated in 20 (65%), 27 (87%) and 29 (94%) patients, respectively. The CT was inconclusive in 4 patients having DRE and colonoscopy information, tumor was incorrectly localized in 2 patients and could not be identified in 1. The mean length of anorectal cancers was 5.1 cm (95%, CI, 4.2-6.1) by PET/CT, 4 cm (95%, CI, 3.02-4.9) by ERUS, 3.8 cm (95%, CI, 3.3-4.5) by DRE, and 5.2 cm (95%, CI, 4.1-6.4) by colonoscopy. When ERUS, DRE, and colonoscopy results were available for all patients (15), the tumor length by PET/CT correlated best with ERUS (r = 0.82, Pearson correlation coefficient). In addition, PET/CT treatment planning helped to determine nodal disease in 3 patients, metastatic disease in 2, and 5 patients were clinically upstaged. The FDG-PET/CT enabled tumor identification and volume measurement in all 31 patients. Tumor length on ERUS, DRE, and colonoscopy was evaluated in 20 (65%), 27 (87%) and 29 (94%) patients, respectively. The CT was inconclusive in 4 patients having DRE and colonoscopy information, tumor was incorrectly localized in 2 patients and could not be identified in 1. The mean length of anorectal cancers was 5.1 cm (95%, CI, 4.2-6.1) by PET/CT, 4 cm (95%, CI, 3.02-4.9) by ERUS, 3.8 cm (95%, CI, 3.3-4.5) by DRE, and 5.2 cm (95%, CI, 4.1-6.4) by colonoscopy. When ERUS, DRE, and colonoscopy results were available for all patients (15), the tumor length by PET/CT correlated best with ERUS (r = 0.82, Pearson correlation coefficient). In addition, PET/CT treatment planning helped to determine nodal disease in 3 patients, metastatic disease in 2, and 5 patients were clinically upstaged. ConclusionsMultiple factors including stenotic lesions, patient discomfort, and rectal scarring adversely affect accuracy of DRE, ERUS, and colonoscopy. Furthermore, DRE, and colonoscopy evaluation of tumor volume is limited to 2-dimensions and CT does not always identify tumor. The FDG-PET/CT has significant impact on both target volume evaluation and staging and may reduce the risk of geographic target misses with conformal radiotherapy. An automated region-growing algorithm for delineation on PET images will be incorporated into our protocol to minimize inter-observer variability errors. Multiple factors including stenotic lesions, patient discomfort, and rectal scarring adversely affect accuracy of DRE, ERUS, and colonoscopy. Furthermore, DRE, and colonoscopy evaluation of tumor volume is limited to 2-dimensions and CT does not always identify tumor. The FDG-PET/CT has significant impact on both target volume evaluation and staging and may reduce the risk of geographic target misses with conformal radiotherapy. An automated region-growing algorithm for delineation on PET images will be incorporated into our protocol to minimize inter-observer variability errors.

Purpose: To evaluate the commercial CMS Monaco IMRT treatment planning system which employs a Monte Carlo (MC) based dose calculation engine, biological motivated cost functions, multi-criteria optimization, and an efficient sequencing algorithm. Method and Materials: For a head and neck, a liver, a prostate and a rectal cancer patient, step-and-shoot IMRT plans were designed using Monaco. The plans were compared to ones generated by the established CMS XiO treatment planning system. The plans were optimized to achieve the same clinical objectives concerning dose to the tumor and to the relevant organs-at-risk. However, whereas the XiO plans were formulated using DVH and minimum/maximum dose constraints, the Monaco plans utilized the biological cost functions offered by the system. DVHs, EUD, mean- and maximum-doses were compared, as well as the number of beam segments and MUs. Finally the plans were delivered on a MapCheck device to verify the agreement between the MC calculated dose distributions and measurements to be less than 3% and 3 mm. Results: Plans optimized with Monaco achieved at least similar and in some cases superior dose distributions. The multi-criteria optimization tools and the sensitivity analysis helped to reduce the time needed to optimize the plan. The Monaco plans resulted in fewer segments and lower number of MUs and therefore reduced delivery time. All calculated dose distributions passed the dose verification with the MapCheck device. Conclusion: The commercially available Monaco system produces clinical relevant plans, which are dosimetrically equivalent or superior to plans from the conventional XiO system, feature shorter delivery times, and can easily be verified with normal QA procedures using MapCheck.

Purpose: To develop an integrated technique to individualize treatment planning (TP) and management of inter- and intra-fraction motion for NSCLC patients treated with 3DCRT or SBRT. Method and Materials: The technique involves first using MV-CBCT in a cine mode prior to planning for optimal beam angle selection and verification of ITV and PTV 4DCT planning-based margins. The angles are selected based on optimal geometrical tumor mass separation with respect to the surrounding OARs and optimal viewing of tumor motion in longitudinal (superior-inferior/SI), vertical (anterior-posterior/AP), and lateral (left-right/LR) directions. Secondly, MV-CBCT is used for daily tumor volume localization just prior to treatment. Thirdly, the EPID is deployed during treatment delivery to verify tumor motion and margins by capturing 7 frames per sec over 30 sec. Since the beam angles were selected to optimally view the target motion, the clinical benefits of using MV-fluoroscopy (MV-fluoro) to monitor tumor motion are maximized. To improve the contrast-to-noise ratio on the CB projection data and MV-fluoro image frames, post-processing with filtering techniques was used. Volumes of interest from the planning 4DCT were projected onto the MV-cine and MV-fluoro. Results: Data show optimal planning beam angles that ensured highly conformal dose distributions and viewing tumor motion in SI, AP, and LR directions derived from the cine data were feasible. The patient tumor volume was localized with MV-CBCT, which represents an average static volumetric image of the patient over 60 sec. The MV-fluoro data confirmed the tumor mass was located within the PTV during treatment despite respiratory motion. Conclusion: Individualizing margins using 4DCT, deriving optimal beam angles based on quasi 3D motion data from MV-cine, localizing with CB, and verifying tumor motion and margins with MV-fluoro is a clinically viable integrated technique, allowing for inter- and intra-fraction motion management.