Dosimetric impact of intrafraction patient motion on MLC‐based 3D‐conformal spatially fractionated radiation therapy treatment of large and bulky tumors

Abstract Purpose To evaluate the dosimetric impact on spatially fractionated radiation therapy (SFRT) plan quality due to intrafraction patient motion via multi‐field MLC‐based method for treating large and bulky (≥8 cm) unresectable tumors. Methods For large tumors, a cone beam CT‐guided 3D conformal MLC‐based SFRT method was utilized with 15 Gy prescription. An MLC GTV‐fitting algorithm provided 1 cm diameter apertures with a 2 cm center‐to‐center distance at the isocenter. This generated a highly heterogeneous sieve‐like dose distribution within an hour, enabling same‐day SFRT treatment. Fifteen previously treated SFRT patients were analyzed (5 head & neck [H&N], 5 chest and lungs, and 5 abdominal and pelvis masses). For each plan, intrafraction motion errors were simulated by incrementally shifting original isocenters of each field in different x‐, y‐, and z‐directions from 1 to 5 mm. The dosimetric metrics analyzed were: peak‐to‐valley‐dose‐ratio (PVDR), percentage of GTV receiving 7.5 Gy, GTV mean dose, and maximum dose to organs‐at‐risk (OARs). Results For ±1, ±2, ±3, ±4, and ±5 mm isocenter shifts: PVDR dropped by 3.9%, 3.8%, 4.0%, 4.1%, and 5.5% on average respectively. The GTV(V7.5) remained within 0.2%, and the GTV mean dose remained within 3.3% on average, compared to the original plans. The average PVDR drop for 5 mm shifts was 4.2% for H&N cases, 10% for chest and lung, and 2.2% for abdominal and pelvis cases. OAR doses also increased. The maximum dose to the spinal cord increased by up to 17 cGy in H&N plans, mean lung dose (MLD) changed was small for chest/lung, but the bowel dose varied up to 100 cGy for abdominal and pelvis cases. Conclusion Due to tumor size, location, and characteristics of MLC‐based SFRT, isocenter shifts of up to ±5 mm in different directions had moderate effects on PVDR for H&N and pelvic tumors and a larger effect on chest tumors. The dosimetric impact on OAR doses depended on the treatment site. Site‐specific patient masks, Vac‐Lok bags, and proper immobilization devices similar to SBRT/SRT setups should be used to minimize these effects.