Multiple breath-hold segmented volumetric modulated arc therapy under real-time fluoroscopic image guidance with implanted fiducial markers: preliminary clinical experience

A technique for multiple breath-hold segmented volumetric modulated arc therapy (VMAT) has been proposed under real-time fluoroscopic image guidance with implanted fiducial markers. Fiducial markers were embedded as close as possible to a tumour and the patient was asked to breathe in slowly under fluoroscopy. Immediately after the marker positions on the fluoroscopic image moved inside the planned marker contours transferred from a digitally reconstructed radiographic image at each gantry start angle, the patient was asked to hold their breath and a segmented VMAT beam was delivered. During beam delivery, the breath-hold status was continuously monitored by viewing a pointer in a breath monitoring system, Abches (Apex Medical, Tokyo, Japan), with the aid of a video camera installed in the treatment room. As long as the pointer stayed still, the segmented VMAT delivery continued for a preset period of 15–30 s, depending on the breath-hold capability of each patient. As soon as each segmented delivery was completed, the beam interrupt button was pushed; subsequently, the patient was asked to breathe freely. Because the preset breath-hold period was determined in order for each patient to hold their breath without fail, an intermediate beam interrupt due to breath-hold failure during the segmented beam delivery was not observed. This procedure was repeated until all the segmented VMAT beams were delivered. A case of pancreatic cancer is reported here as a preliminary study. The proposed technique may be clinically advantageous for treating tumours that move with respiration, including pancreatic cancer, lung tumour and other abdominal cancers.