Patterns Of Practice in Adaptive and Real-Time Particle Therapy (POP-ART PT), Part I: intrafractional respiratory motion

Purpose/objectives: For particle therapy, the clinical implementation of Real-time Respiratory Motion Management (RRMM) is of vital importance to mitigate the detrimental effects of motion on dose delivery. We introduced a worldwide questionnaire on the Patterns of Practice for Adaptive and Real-time Particle Therapy (POP-ART PT), aiming to determine the current status and the potential barriers for motion management implementation in clinical practice at particle therapy centers. Here we summarize the result of RRMM implementation at European centers.
Material and methods: A questionnaire was distributed worldwide to evaluate the current clinical practice, wishes for expansion and barriers to new implementation. Two types of RRMM technique were considered: 1) passive, using volumetric/layered rescanning, 2) active, using free-breathing gating, breath-hold (BH), or tracking/synchronization where beam and target are continuously re-aligned. The tumor sites breast, lung, liver, pancreas, esophagus, and lymphoma were specifically surveyed.
Results: Answers from 44 centers from 16 countries worldwide have been received so far. Here we present the results for 23 European centers from 13 countries (92% response rate). RRMM was used in 16(69%) centers clinically, of which 5(22%) have both passive and active method implemented (figure 1). Of the 22 centers using pencil beam scanning, 13(56%) were applying rescanning, 7(31%) indicated the plan to implement it in the future, and 2(9%) reported rescanning incompatibility due to machine limitations. However, no clear agreement on an optimal rescanning method was found, as 6/7 centers used layered/volumetric rescanning with large variations in rescan numbers (2-6 times). Only 8(34%) centers have been using BH/gating as active RRMM in at least one tumour site (Lymphoma: 100%), but all centers wished to implement it in the future. Surface motion or breathing volume monitoring was the most common method to guide active RRMM. Four centers (…% of those using active RRMM) provided audio/visual feedback to the patient with 2 acquiring additional images to verify surrogate accuracy during dose delivery. No center conducted separate coaching for BH/gating. No center used or wished to use tracking/motion synchronization in the future. Furthermore, 12(54%) and 20(87%) centers wished to extend the use of active RRMM for current tumour sites and to implement it for new tumour sites, respectively. Priority was given to lung (58% and 83%). The main barriers (figure 2) to extend/implement RRMM for current/new tumour sites were technical limitations, limited equipment and human resources.
Conclusion: 69% of particle therapy centers in Europe have implemented RRMM to mitigate the effects of intrafractional respiratory motion in clinical practice. A significant interest was reported to implement more active RRMM in the future, in particular for lung cancer, requiring more support to address technical limitations.