Lung Cancer Tumor Localization Techniques

Courtney Chaney
December 7th, 2015

More people die from lung cancer than any other cancer. With 210,828 people being
diagnosed each year, this cancer has countless researchers, doctors, and hospitals striving each
day to evolve the radiotherapy used. With the lung being an organ which has an ample amount
of movement, doctors need to utilize procedures in which encompass the entire tumor at all
times. To accomplish full coverage during treatment, a doctor can pinpoint the tumors
placement by manipulating the patients breathing pattern, whether it be through a gating or
breath hold method. While some doctors use these methods, others instead track the tumors
movement inside the lung on a four dimensional CT scan and create a treatment volume that
covers the tumors entire travel distance inside the lung. Each method of tumor localization has
advantages, but is not always suitable for all patients. The localization of the tumor has immense
importance and can be the direct cause for failure of the radiotherapy treatment and an over dose
of radiation to the normal surrounding tissue. All the articles I have chosen to review hone in on
the advantages of the new localization methods in comparison to the once standard treatment
localization methods. In order to explain in further detail and give the general advantages one
method has over another, three studies have been reviewed and evaluated.
In the article, Monte Carlo calculations support organ sparing in DeepInspiration Breath Hold intensity modulated therapy for locally advanced lung cancer conducted
by the researchers W. Ottosson et al, the advantages of the breath holding technique during lung
cancer radiotherapy exemplified. The study included eighteen patients who had locally
advanced lung cancer. Each patient underwent a free breathing CT scan, which is standard, and
also a deep inspiration breath hold (DIBH) scan. From each scan an intensity modulated
radiation therapy (IMRT) plan was created for that patient for a prescription of 66 Gy in 33
fractions. Each plan was then evaluated in terms of its lung volume, dose to normal surrounding

tissue (OAR), dose deviations, and gross tumor volume. After all eighteen patients plans had
been compared, the results concluded that the DIBH compared with FB can significantly reduce
the dose to the OARs. For the OARs, DIBH reduced the mean heart dose by 25.5% and the
total lung by 20.0%. In terms of dose deviations, they were similar for both techniques.
Relative to FB, the total lung volume increased 86.8% in DIBH, while the gross tumor volume
decreased 14.8%.
This study supports the theories that having a DIBH can precisely measure the tumor
volume by the means of decreasing the volume the physicians contour to treat, which in turn
saves the OARs unnecessary dose. This type of technique has mad advances in lung cancer
treatment which greatly benefit the patient and the treatment efficiency. This study excelled by
using the same stage of advancement cancer patients and producing both types of scans for each
patients. Providing both scans gave us great internal validity to show that the differences and
advantages produced are truly because of the deep inspiration. While the researchers experiment
did fall short on external validity because the sample size of 18 is too small to provide an
adequate representation of the entire population. The researchers also failed to include the exact
stage and histology of each patient which is a determining factor when doctors prescribe
treatments to patients. The study, although it did not provide many participants, provides
explanation as to why this technique could be superior to the standard method because by
diminishing the movement the tumor size shrinks and stabilizing the location so that the external
beams of radiation can achieve the greatest effect.
In the study Dosimetric and Clinical Benefits of Respiratory-Gated Radiotherapy for
Lung and Breast Cancers: Results of the STIC 2003 by Giraud et al, the respiratory gated
approach to radiotherapy is evaluated. This was a comparative, non-randomized, multicenter

and prospective study that included 20 French centers between April 2004 and June 2008 that
consisted of a total of 401 non-small cells lung cancer. The researchers objective was to
compare respiratory-gated conformal radiotherapy versus conventional conformal radiotherapy
for the irradiation of non-small cell lung cancer. The researchers had a group of participants
assigned to receive conventional conformal radiotherapy which the others were chosen to receive
a respiratory gated conformal therapy. When the results of each study group had been compared
the respiratory gated patients provided advantages that made treating conventionally seem
prehistoric. The final results confirmed the feasibility and good reproducibility of the
respiratory-gated therapy regardless of tumor location. The results of this study demonstrated a
reduction of dosimetric parameters predictive of pulmonary, cardiac and esophageal toxicity,
especially for non-small cells lung cancer, as a result of the respiratory gating techniques. These
benefits were correlated with a significant reduction in acute and late toxicities, especially for the
pulmonary system, the lung and heart specifically. These benefits seem superior to conventional
treatment methods and truly helps solidify the need for treatment evolution. If one were to be
content with the standard ways of treatment then no one would ever have discovered the
increased benefits of the respiratory gated technique. I feel as though because this article
presented so many more advantages this technique is more adequate than the breath hold.
This study included adequate amounts of information so that one would be able to see the
advantages of the technique easily, although I would like to have seen more of a variety of lung
cancer patients instead of just including non-small cell histologies because a lot of cancers are
small cell and one cannot be deemed as a new standard if it cannot be applied to all lung cancers.
Including only non-small cell patients did have a purpose though because it ensured internal
validity. I do commend the research team for including a large quantity of participants. The study

also included conventional and gated data which helps back up their claims. This was a very well
put together experiment. The trial was randomized which increased internal validity.
In the Ehrbar et al article the research team compared 3D and 4DCT planning techniques
for volumetric modulated therapy.
The group took 9 previously treated small cell lung patients and gave them a 4DCT scan.
The researchers then reviewed the CT and drew on an internal movement target volume (ITV) in
which was composed of the margins of the tumor during the lungs motion. The 4D dose was
accumulated with rigid as well as deformable registrations of the CT series and compared to the
original 3D dose distribution. Maximum, minimum and mean doses to the target and the organs
that surround the tumor at risk (OAR) were evaluated. The resulting conclusions consisted of
the dose parameters between 3D and 4D dose calculations being -2.1% to 1.4% for all target
volumes and within -0.8% to 1.7% in OAR. Using deformable registrations, dose differences in
the GTV were below 3.8% for dose accumulation. The experiment reviewed the exams and
described the results in good detail. I do think the experiment could be changed for the better by
including more patients and performing the conventional therapy on the patient's scan instead of
taking the standard values.
I feel manipulating the breathing techniques of the lung patients is a brilliant idea and
truly makes me wonder why we have not taken this as a standard for all patients yet. Based on
the information in the articles I cant say which technique is truly best but one of the three should
be utilized for every lung cancer patient. After reviewing all three articles I feel the researchers
may have been biased so the true comparison can only be achieved if one picked apart each
experiment. The researchers did not include which people who had to be excluded in their
studies, why, or what could be changed and I feel one would have to have all of that information

to truly decided which treatment method helps localize the tumor best. Based off opinion only, I
feel like DIBH treatment has advantages but it is not the best treatment choice because of the
variability of the lung expansion, I dont think that getting the exact replication of tumor location
would be superior to 4d CT tumor measurement or respiratory gating. The respiratory gating is a
free breathing technique so because of that I feel as though this takes some of the stress of
getting it right off the patient and adds a more comfortable situation and set up for the patient
which is easy for the patient to recreate. The 4D tumor measurement I feel encompasses the
comfortability and reproducibility of the gating technique but I feel that because we treat the
entire tumor traveling distance that we have the potential to treat more normal lung. Although
treating more normal lung is something we would not want to do, it may be necessary in this
technique to ensure the entire tumor is treated and does not receive an under dose and fails to rid
the patient of the tumor.
The DIBH article emphasized the techniques ability to spare the normal tissues
surrounding the tumor, decrease the tumor size to decrease OAR dose, and increases the lung
volume which emphasizes that conventional treatments dont have the exact measurements that
can offer the optimal treatments. In the Giraud et al article the gating technique exemplified less
dose to the pulmonary system and surrounding tissues. The researchers also confirmed that the
gating setup was feasible and ensured reproducibility. The final article of the 4D scan embodies
the aggressive nature we try to embody with our treatments, but it also adds unwanted benefits of
treating extra lung. I think further study of all three of the methods simultaneously compared to
each other needs to be ran in order to move forward in solidifying a new standard for lung
cancer. Also, I think that all lung cancer types need to be compared in each technique against

each other so that the radiation therapy departments can have the full strengths and weaknesses
of each methods.

REFERENCES
1. U.S. Cancer Statistics Working Group. United States Cancer Statistics: 19992012
Incidence and Mortality Web-based Report. Atlanta (GA): Department of Health
and Human Services, Centers for Disease Control and Prevention, and National
Cancer Institute; 2015.
2. Ottosson W, Sibolt P, Larsen C, Lykkegaard Andersen JA, Borissova S, Mellemgaard A,
Behrens CF. Monte Carlo calculations support organ sparing in Deep-Inspiration
Breath-Hold intensity-modulated radiotherapy for locally advanced lung cancer. October
2015. PubMed.com December 2015.
3. Giraud P, Djadi-Prat J, Morvan E, et al. Dosimetric and clinical benefits of respiratory-gated
radiotherapy for lung and breast cancers: results of the STIC 2003. July 2012.
PubMed.com December 2015.
4. Ehrbar, Lang, Stieb S, Riesterer O, Stark LS, Guckenberger M, Klck S. Three-dimensional
versus four-dimensional dose calculation. July 14, 2015. PubMed.com December 2015.