Intrafractional Internal Organ Movement (IOM)

Internal organs have the ability to shift during both voluntary and involuntary movements in our daily activities. Organs can move voluntarily with the stride of a runner or a simple abdominal stretch, whereas involuntary organ movement is not near as literal. While patients are not stretching or running during a radiation therapy treatment, it is more imperative to account for involuntary organ movements that can cause significant anatomical changes. Intrafractional organ movement (IOM) is characterized by the movement of internal organs during radiation therapy treatment. Intrafractional IOM should not be confused with interfractional IOM. Interfractional IOM accounts for differences in patient movement between fractions and errors in patient set-up. Because the prefix intra- means within, you can remember intrafractional as within a fraction. Specifically, intrafractional IOM is a result of respiratory or cardiac motion and is most notable in the treatment of abdominal cancers.1 The organs that are influenced the most by this involuntary motion are lungs, diaphragm, liver, kidneys, pancreas and the prostate.1 Intrafractional IOM can cause several problems in patient treatment, the most significant being the probability of missing part or all of the tumor volume and irradiating normal tissues with prescription dose. The figure below is representative of how organ movement influences the coverage index (a), conformity index (b), homogeneity index (c) and equivalent uniform dose (d) for a prostate treatment.2

In all 4 cases, anterior/posterior (AP) and posterior/anterior (PA) intrafractional movement of the prostate provided the most substantial difference. Provided the inhalation and exhalation (AP/PA movement) are responsible for the most intrafractional movement, the management of this movement is crucial. It is most difficult to account for cardiac rythyms considering stopping the heart is obviously not an option. However, advancements in technology have allowed us to account for organ movement during respiratory cycles. Management techniques include voluntary breath holding, deep inspiration breath-hold, respiration-gated irradiation, forced breath holding or active breathing control, organ position tracking and abdominal pressure. I encourage you to visit this website
(www.medphys.mcgill.ca/presentations/liheng2003.pdf) to get a better understanding of the differences between interfractional IOM, intrafractional IOM and organ movement. This powerpoint also provided an excellent introduction to each of the management techniques I mentioned.

Dynamic IMRT
As technology progresses in the field of radiation oncology, better treatment techniques are developed. The introduction of Intensity Modulated Radiation Therapy (IMRT) revolutionized the radiation therapy industry in the 1990s. IMRT provided the means for obtaining radiation oncologys most important goal: completely eradicating tumor cells while giving very little dose to normal tissues. Since then, new technologies have advanced the treatment planning of IMRT, specifically in the area of treatment techniques. Static IMRT only allows the delivery to radiation when the gantry is in a fixed position. However, dynamic IMRT gives the radiation therapy staff the ability to plan and treat the patient continuously while the gantry rotates. Dynamic IMRT has obvious benefits in treatment, the most significant being decreased treatment time. The less time the patient is on the table, the more likely they are to cooperate with immobilization. Another benefit to dynamic IMRT is that the treatment planning system (TPS) algorithm more accurately reflects the patients actual treatment.3It is extremely important that the TPS reflects treatment accurately. The planner needs to understand exactly what will happen during patient treatment. A major downfall to dynamic IMRT is the increased monitor units that are delivered continuously around the patient. We would assume that while the beam is on continuously, integral and low dose structures would increase. However, a study analyzing static IMRT and dynamic IMRT found the differences in integral dose and low dose to be minute.3 The most common type of dynamic IMRT is volumetic modulated arc therapy (VMAT). This video http://www.youtube.com/watch?v=wxBEdMJfxRo&NR=1&feature=fvwp is a great example of the VMAT technology offered by Elekta and I would encourage you to watch

to understand the concept better.

References 1. Liang, L. Organ Motion and its Management. McGill Medical Physics Unit Web site. www.medphys.mcgill.ca/presentations/liheng2003.pdf. Accessed April 2, 2013. 2. Yoon M, Kim D, Shin D, et al. Inter-and intrafractional movement-induced dose reduction of prostate target volume in proton beam treatment. Int J Radiat Oncol Biol Phys. 2008;71(4): 1091-1102. 3. Jothybasu K, Bahl A, Subramani V, et al. Static versus dynamic intensitymodulated radiotherapy: profile of integral dose in carcinoma of the nasopharynx. J Med Phys. 2009;34(2): 66-72. Doi: 10.4103/0971-6203.51932