Step and shoot IMRT to mobile targets and techniques to mitigate the interplay effect

The purpose of this work is to evaluate a method to mitigate temporal dose variation due to the interplay effect as well as investigate the effect of randomly varying motion patterns. The multi-leaf collimator (MLC) settings from 5, 9 and 11 field step and shoot intensity modulated radiation therapy (IMRT) of non-small cell lung cancer (NSCLC) treatment plans with tumor motion of 1.53, 1.03 and 1.95 cm, respectively, were used. Static planar dose distributions were determined for each treatment field using the Planar Dose Module in the Pinnacle³ treatment planning system. The MotionSIM XY/4D robotic diode array was used to recreate the tumor motion orthogonal to each treatment beam. Dose rate modulation was investigated as a method to mitigate temporal dose variation due to the interplay effect. Computer simulation was able to identify individual fields where interplay effects are greatest. Computer simulation and physical measurement have shown that temporal dose variation can be mitigated by the selection of the dose rate or by selective dose rate modulation within a given IMRT treatment field. Selective dose rate modulation within a given IMRT treatment field reduced temporal dose variation to levels comparable to whole field dose rate reduction, while also producing shorter radiation delivery times in six of the seven cases investigated. For the cases considered, the interplay effect did not appear to have a greater effect on hypofractionation compared to traditional fractionation even though fewer fractions were delivered. Randomized motion kernel variation was also considered. For this portion of the study, a nine field step and shoot IMRT configuration was considered with a 1.03 cm tumor motion rather than the five field case. In general, if the extent of the variant motion pattern was mostly contained within the target volume, limited impact on the temporal dose variation was observed. In cases where the variant motion kernels increasingly exceeded the target volume limits, increases in temporal dose variation were observed.