A preliminary investigation of re‐evaluating the irradiation dose in hepatocellular carcinoma radiotherapy applying 4D CT and deformable registration

PURPOSE: To investigate the effect of breathing motion on dose distribution for hepatocellular carcinoma (HCC) patients using four‐dimensional (4D) CT and deformable registration. METHODS: Fifty HCC patients who were going to receive radiotherapy were enrolled in this study. All patients had been treated with transarterial chemoembolization beforehand. Three‐dimensional (3D) and 4D CT scans in free breathing were acquired sequentially. Volumetric modulated arc therapy (VMAT) was planned on the 3D CT images and maximum intensity projection (MIP) images. Thus, the 3D dose (Dose‐(3D)) and MIP dose (Dose‐(MIP)) were obtained, respectively. Then, the Dose‐(3D) and Dose‐(MIP) were recalculated on 10 phases of 4D CT images, respectively, in which the end‐inhale and end‐exhale phase doses were defined as Dose‐(3D‐EI), Dose‐(3D‐EE), Dose‐(MIP‐EI), and Dose‐(MIP‐EE). The 4D dose (Dose‐(4D‐3D) and Dose‐(4D‐MIP)) were obtained by deforming 10 phase doses to the end‐exhale CT to accumulate. The dosimetric difference in Dose‐(3D), Dose‐(EI3D), Dose‐(EE3D), Dose‐(4D‐3D), Dose‐(MIP), Dose‐(EIMIP), Dose‐(EEMIP), and Dose‐(4D‐MIP) were compared to evaluate the motion effect on dose delivery to the planning target volume (PTV) and normal liver. RESULTS: Compared with Dose‐(3D), PTV D99 in Dose‐(EI3D), Dose‐(EE3D) and Dose‐(4D‐3D) decreased by an average of 6.02%, 1.32%, 2.43%, respectively (P < 0.05); while PTV D95 decreased by an average of 3.34%, 1.51%, 1.93%, respectively (P < 0.05). However, CI and HI of the PTV in Dose‐(3D) was superior to the other three distributions (P < 0.05). There was no significant differences for the PTV between Dose‐(EI) and Dose‐(EE), and between the two extreme phase doses and Dose‐(4D) (P> 0.05). Negligible difference was observed for normal liver in all dose distributions (P> 0.05). CONCLUSIONS: Four‐dimensional dose calculations potentially ensure target volume coverage when breathing motion may affect the dose distribution. Dose escalation can be considered to improve the local control of HCC on the basis of accurately predicting the probability of radiation‐induced liver disease.