Int. J. Radiation Oncology Biol. Phys., Vol. 51, No. 4, pp.

932–937, 2001
Copyright © 2001 Elsevier Science Inc.
Printed in the USA. All rights reserved
0360-3016/01/$–see front matter

PII S0360-3016(01)01716-3

CLINICAL INVESTIGATION Lung

MULTIPLE “SLOW” CT SCANS FOR INCORPORATING LUNG TUMOR

MOBILITY IN RADIOTHERAPY PLANNING

FRANK J. LAGERWAARD, M.D.,* JOHN R. VAN SORNSEN DE KOSTE,* MARGRIET R.J. NIJSSEN-VISSER,*
REGINE H. SCHUCHHARD-SCHIPPER,* SWIE SWAT OEI, M.D.,* ARISTOTELES MUNNE,† AND
SURESH SENAN, M.R.C.P., F.R.C.R., PH.D.*
Departments of *Radiation Oncology and †Radiology, University Hospital Rotterdam, Rotterdam, The Netherlands

Purpose: The high local recurrence rates after radiotherapy in early-stage lung cancer may be due to geometric
errors that arise when target volumes are generated using fast spiral CT scanners. A “slow” CT technique that
generates more representative target volumes was evaluated.
Methods and Materials: Planning CT scans (slice thickness 3 mm, reconstruction index 2.5 mm) were performed
during quiet respiration in 10 patients with peripheral lung lesions. Planning CT scans were repeated twice,
followed by three slow CT scans (slice thickness 4 mm, index 3 mm, revolution time 4 s/slice). All, except the first
scan, were limited to the tumor region. Three-dimensional registration of all scans was performed. The
reproducibility of the imaged volumes was evaluated with each technique using (1) the common overlapping
volume (COM), the component of the clinical target volume (CTV) covered by all three CT scans, and (2) the
encompassing volume (SUM), which is the volume enveloped by all CTVs.
Results: In all patients, the target volumes generated using slow CT scans were larger than those derived using
planning scans (mean ratio of planning-CTV:slow-CTV of 88.8% ⴞ 5.6%), and also more reproducible. The
mean ratio of the respective COM:SUM volumes was 62.6% ⴞ 10.8% and 54.9% ⴞ 12.9%.
Conclusions: Larger, and more reproducible, target volumes are generated for peripheral lung tumors with the
use of slow CT scans, thereby indicating that slow scans can better capture tumor movement. © 2001 Elsevier
Science Inc.

Lung cancer, Tumor mobility, Planning CT scan, Geometric errors.

INTRODUCTION arising from external setup deviations at the treatment unit,

The local control rates achieved after radiotherapy (RT) in
patients with medically inoperable Stage I non–small-cell
lung cancer (NSCLC) are inferior to those obtained with
surgery. Overall 3- and 5-year survival rates were 31% and
15%, and the corresponding cancer-specific survival was
only 42% and 31%, respectively, after doses between 60
and 65 Gy (1). Uncontrolled lung cancer remains the pri-
mary cause of death in these patients, and local failure alone
has been reported to occur in up to 49% of patients (2).
Early experience with three-dimensional (3D) RT tech-
niques suggests that doses in the order of 84 Gy or higher
are necessary for a greater than 50% probability of local
tumor control (3). A recent dose escalation study has shown
that doses up to 102 Gy are feasible for peripheral lung
tumors (4).
In recent years, the role of geometric errors in RT treat-
ment planning and delivery for lung cancer has attracted
much attention. Such errors may be broadly categorized as
or from tumor movement within the patient. The former can
be minimized by the use of off-line setup correction proto-
cols (5, 6), but the mobility of lung tumors because of
respiration and cardiac action continues to pose a formida-
ble problem. In most institutions, the RT treatment planning
CT scan is acquired during quiet respiration, based on the
assumption that the generated target volume will correspond
to the position of the target during daily treatments, which
are also performed during quiet respiration.
However, analysis using fast CT scans shows that signif-
icant tumor movement occurs in lesions located in the
proximity of the heart, diaphragm, and lung hilus (7). Sim-
ilarly, sequential CT scanning at the table position at which
a prior scan had identified the slice showing the maximum
tumor diameter completely failed to visualize any tumor in
21% of images (8). The short sampling times of modern CT
scanners relative to the respiratory cycle may result in a
failure to generate a reliable 3D target volume for treatment

Reprint requests to: Suresh Senan, Department of Radiation
Oncology, University Hospital Rotterdam, Groene Hilledijk 301,
3075 EA, Rotterdam, The Netherlands. Tel: ⫹31 10 4391116; Fax:
⫹31 10 4391013; E-mail: senan@rtdh.azr.nl
Acknowledgments—We thank Dr. J. Geleijns, Department of Ra-
diology, Leiden University Medical Center, The Netherlands, for
the calculation of radiation exposure resulting from the different
CT scan techniques.
Received Dec 27, 2000, and in revised form May 15, 2001.
Accepted for publication Jun 4, 2001.

932
 Multiple “slow” CT scans for assessment of tumor mobility
Table 1. Characteristics of study patients
Patient Stage Location
A T2N0M0 Left upper lobe, adjacent to mediastinum
B T1N0M0 Left upper lobe, subpleural
C T1N0M0 Right upper lobe, subpleural
D T1N0M0 Right upper lobe, central
E T1N0M0 Left upper lobe, central
F T2N0M0 Left upper lobe, subpleural
G T1N0M0 Right upper lobe, central
H T1N0M0 Right upper lobe, subpleural
I T1N0M0 Left lower lobe, central
J T1N0M0 Left upper lobe, subpleural
planning (9). Such work has called into question the use of
3D treatment planning in its current form to improve local
tumor control in Stage I NSCLC patients.
One method of addressing tumor mobility would be to
irradiate patients during a deep-inspiration breath-hold
(DIBH) maneuver, during which mobility arising from res-
piration will be avoided, and the irradiated volume of lung
tissue will be minimized as a result of the hyperinflation of
the lung (10). Because this approach requires the use of
respiration-gated CT scanning and treatment, both of which
are not available at our institute, we explored alternative
methods of addressing the problem of target mobility.
We describe here a technique of “slow” CT scanning that
enables the 3D movement of lung tumors to be character-
ized on a standard spiral CT scanner, thereby allowing more
representative planning data to be generated for patients
with peripheral lung tumors.
METHODS AND MATERIALS
Planning CT scans (ACQSIM, Marconi Medical Sys-
tems, slice thickness 3 mm, index 2.5 mm, pitch 2) were
performed during quiet respiration in 10 patients who pre-
sented with peripherally located NSCLC (Table 1, Patients
A–J). Patients were immobilized using a lung board with
adjustable arm rests (6). The cranial and caudal extent of the
initial standard planning scan was the subcricoid region and
the second lumbar vertebra, respectively. Intravenous con-
trast was used only if tumors were located in the proximity
of the hilus or great vessels. An isocenter for treatment
planning, generally located at the center of the tumor mass,
was defined using this CT scan and demarcated using ink
and tattoos on the patient’s skin.
Immediately after the treatment planning CT scan, addi-
tional scans, restricted to the region of interest, were per-
formed to study tumor mobility. The planning scan was
repeated twice in all patients using the same CT parameters.
Next, three slow CT scans were performed using 4 s per
rotation and a pitch of 1. Scanning parameters are shown in
Table 2. Thus, a total of three planning and three slow scans
were available for each patient for the analysis of tumor
mobility and reproducibility of both scanning techniques.
Information from all CT scans was used to define the actual
● F. J. LAGERWAARD et al. 933
Table 2. Parameters of both CT techniques
Slice
thickness Index mAs Pitch Sec./Rev.*
Planning CT 3.0 mm 2.5 mm 175 2.0 1
Slow CT 4.0 mm 3.0 mm 50 1.0 4
* Time (seconds) per CT revolution.
clinical target volume (CTV) used for treatment. The entire
scanning procedure required approximately 45 min per pa-
tient, and the duration of a single limited slow scan was
comparable to the time required to perform the initial com-
plete planning CT scan. As slow CT scans were limited to
the region of interest, the radiation exposure arising from
this scan was calculated at between 20% and 25% of that of
a standard planning CT scan.
Image registration of all CT data sets was performed
using the contour matching software tool (ACQSIM version
4.0.5), an object-based registration method with contour
segmentation. A thoracic vertebra adjacent to the tumor was
contoured on all CT data sets using predefined window level
settings and magnification factor. Vertebrae were used for
matching, because they represented nondeformable struc-
tures without motion artifacts. All image registrations were
performed by one radiation oncologist and then evaluated
by the other (F.J.L., S.S.). The accuracy of the registration
method was within 1 mm in all cases.
The gross tumor volume (GTV) was contoured on all
registered CT data sets by a clinician at an ACQSIM work-
station using a preset lung window setting and a standard
contouring protocol (11). The following volumes were gen-
erated: (1) planning GTVs, derived from rapid CT scans,
and (2) slow GTVs, derived from the slow scans. After
image registration, all contours were automatically pro-
jected onto the initial planning CT scan, which was used for
further analyses. CTVs were generated after the 3D addition
of a 5-mm margin for microscopic tumor extension. To
evaluate the reproducibility of both scanning techniques,
two additional volumes were manually contoured. The com-
mon overlapping volume (COM) was defined as the com-
ponent of the CTV that was covered by all three scans using
a specific CT technique. The encompassing volume (SUM)
was defined as the volume enveloped by CTVs from all
three CT scans of a specific technique (Fig. 1). Volumetric
calculations of these CTVs were performed using Cadplan
(Dosetek-Varian v. 3.1).
RESULTS
The volume of the CTVs generated using the two CT
techniques (Table 3)
For each patient, the mean CTV derived using the two CT
techniques is shown in Table 3, as is the ratio of the mean
planning-CTV to slow-CTV. Target volumes generated us-
ing slow CT scans were invariably larger than those derived
using planning scans, as shown by the mean ratio of plan-
934 I. J. Radiation Oncology ● Biology ● Physics Volume 51, Number 4, 2001

plan:plan-CTV was 71.1% ⫾ 10.8% and ranged from 46.9 –

85.6%. The degree of reproducibility as evaluated using the
mean ratio of the COM-plan and the SUM-plan was 54.9%
⫾ 12.9% (range 30.2–76.0%).
The reproducibility of slow CT scans was evaluated in
the same manner. The reproducibility of slow scans was
better in all but one patient (G), as illustrated by the larger
mean COM-slow:slow-CTV ratio of 77.2% ⫾ 7.8% with a
smaller range (61.3– 89.1%). Similarly, the mean COM:
SUM ratio of 62.6% ⫾ 10.8% (range 41.9 – 80.2%) for the
slow scans was larger than that of planning CT scans.

Number of CT scans necessary for characterizing mobility

Fig. 1. The SUM volume refers to the envelope encompassing all
three scans of the same technique, and the COM volume refers to
the overlapping common volume of all three CT scans.
ning-CTV to slow-CTV of 88.8% ⫾ 5.6% (mean ⫾ 1 SD,
range 81.8 –97.3%). This indicates that tumor mobility is
better imaged when slow CT scans are used. The overlap-
ping component of the CTVs in a specific type of scan
(referred to as COM) was larger for slow CT scans, as
indicated by the ratio COM-plan:COM-slow of 81.2% ⫾
9.3% (range 62.6 –91.4%). The volume enveloped by all
three slow CT scans (referred to as SUM-slow) was some-
what larger than the SUM-plan, as indicated by the ratio
SUM-plan:SUM-slow of 93.5% ⫾ 6.8%, range
81.7–103.2%.
Reproducibility of the scanning techniques (Table 4)
The reproducibility of the target volumes captured by
planning CT scans was analyzed by determining the ratio of
the overlapping area (COM-plan) to individual planning
CTVs for all patients (Table 4). The mean ratio of COM-
(Table 5)
The SUM volumes were derived from three separate slow
or planning CT scans. The coverage of this SUM volume,
when only one or two CT scans from a specific technique
were used, is shown in Table 5. The mean coverage of the
SUM-slow was 80.6% ⫾ 6.1% (range 68.4 –90.0) when
information from only one slow CT scan was used and
increased to 93.3% ⫾ 2.5% (range 87.5–96.9%) when data
from two slow CT scans were used. The comparable data
for SUM-plan were 76.7% ⫾ 6.9% (range 64.6 – 88.8%) and
91.8% ⫾ 2.9% (range 87.7–97.1%) for information from
one or two planning CT scans, respectively.
Comparison of the SUM-plan and SUM-slow volumes
(Table 6)
To incorporate spatial information into the comparison
between planning and slow CT scans, an analysis was
performed to link the SUM-plan and SUM-slow volumes.
The mean percentage of the SUM-slow volume not covered
by the summation of three planning CT scans was 15.7% ⫾
4.9% (range 6.5–24.4%). Alternatively, the mean percent-
age of the SUM-plan volume not covered by the summation
of three slow CT scans was smaller, i.e., 9.7% ⫾ 3.8%
(range 1.7–14.6%), indicating the superiority of slow CT
scans.

Table 3. CTVs and ratios of COM and SUM volumes for different CT scan techniques

Mean plan- Mean slow- Ratio (%) plan-CTV: Ratio (%) COM-plan: Ratio (%) SUM-plan:
CTV (cc) CTV (cc) slow-CTV COM-slow SUM-slow

A 191.7 198.9 96.4 88.0 103.2

B 22.7 23.4 97.3 88.2 101.7
C 17.5 18.7 93.9 91.4 97.6
D 17.0 20.0 84.9 77.1 94.0
E 37.2 43.3 85.9 84.8 88.3
F 75.8 86.4 87.8 83.6 90.9
G 25.0 29.9 83.8 85.8 81.7
H 23.0 28.1 81.8 62.6 86.7
I 30.1 35.7 84.4 67.7 93.2
J 23.1 25.3 91.5 82.7 97.6
Mean ⫾ group SD 88.8 ⫾ 5.6 81.2 ⫾ 9.3 93.5 ⫾ 6.8

Abbreviations: COM ⫽ the component of the CTV that is also covered by the other two CTVs from a specific CT technique; SUM ⫽
volume enveloping all three CT scans from a specific technique; CTV ⫽ clinical target volume.
 Multiple “slow” CT scans for assessment of tumor mobility ● F. J. LAGERWAARD et al. 935

Table 4. Reproducibility of both scanning techniques measured by the ratio between a single CTV and the COM volume, and the ratio
between the COM and SUM volume

A B C D E F G H I J

Mean CTV-plan (cc) 191.7 22.7 17.5 17.0 37.2 75.8 25.0 23.0 30.1 23.1
COM-plan (cc) 156.0 14.7 13.1 11.2 27.2 59.4 21.4 10.8 19.8 16.3
SUM-plan (cc) 228.0 31.4 22.7 24.1 48.6 93.2 28.2 35.6 39.5 30.7
Mean ratio COM/CTV-plan
(%) 81.4 65.5 74.9 66.1 74.1 78.4 85.6 46.9 67.6 70.8
Ratio COM/SUM-plan (%) 68.4 46.9 57.9 46.3 56.0 63.8 76.0 30.2 50.0 53.1

Mean CTV-slow (cc) 198.9 23.4 18.7 20.0 43.3 86.4 29.9 28.1 35.7 25.3
COM-slow (cc) 177.2 16.7 14.4 14.5 32.1 71.1 25.0 17.2 29.2 19.7
SUM-slow (cc) 221.0 30.9 23.2 25.6 55.0 102.5 34.5 41.1 42.4 31.5
Mean ratio COM/CTV-
slow (%) 89.1 71.6 77.1 72.7 74.5 82.4 83.8 61.3 81.7 78.2
Ratio COM/SUM-slow (%) 80.2 54.1 61.8 56.4 58.3 69.4 72.4 41.9 68.8 62.7

Abbreviations: COM ⫽ the component of the CTV that is also covered by the other two CTVs from a specific technique; SUM ⫽
enveloping volume of all three CT scans from a specific technique; CTV ⫽ clinical target volume.

Can multiple slow scans be replaced by a single slow
scan expanded by a 3D margin? (Table 7)
The generation of multiple slow CT scans requires up to
30 min and can be taxing for the CT scan equipment and
sometimes for patients. As such, we studied the coverage of
the SUM-slow volume by CTVs derived from a single slow
CT scan expanded with a 3D margin of 3 mm. A margin that
resulted in at least 95% coverage of the SUM-slow was
considered adequate. An expansion of the CTV derived
from a single slow CT scan with a margin of 3 mm resulted
in a mean coverage of the SUM-slow volume of 96.4% ⫾
3.4%. The CTV-slow expanded with a 3-mm margin also
covered the SUM-plan (95.8% ⫾ 4.8%). However, this
margin of 3 mm was inadequate for 3 patients who had
mobile tumors (C, D, F), and the use of information from all
three slow CT scans provided superior target coverage. In
addition, the use of a 3-mm margin around a single slow-
CTV resulted in a 29% increase in target volume compared
to the SUM-slow volume (Table 8).
Can multiple slow scans be replaced by a single planning
scan expanded by a 3D margin? (Table 7)
Expanding a single plan-CTV with a 3-mm margin re-
sulted in inadequate coverage of the SUM-slow volume in 6
out of 10 patients (mean 89.2% ⫾ 6.3%). However, expan-
sion using a margin of 5 mm ensured full coverage of the
SUM-slow volume (96.1% ⫾ 5.5%), but at the cost of a
56% increase in irradiated volume (Table 8).
DISCUSSION
The high local failure rates reported after high-dose RT for
Stage I medically inoperable NSCLC (2) may be due to factors
such as the earlier use of two-dimensional RT planning, sub-
optimal doses of RT (3), and geographic misses (8). Even 3D
conformal RT, which is delivered to target volumes generated
using rapid CT scans, can result in the treatment of a volume
that is captured at a random point within the respiratory cycle,
thereby introducing possible systematic errors (8, 9). Our anal-

Table 5. Coverage of the encompassing volume (SUM) of slow and planning CT scans versus the number of scans performed

Mean coverage of SUM-slow (%) obtained Mean coverage of SUM-plan (%) obtained
with with

Single slow-CTV Two slow-CTVs Single plan-CTV Two plan-CTVs

A 86.5 ⫾ 4.6 94.6 ⫾ 1.5 88.8 ⫾ 1.1 97.1 ⫾ 2.2

B 80.4 ⫾ 5.7 93.4 ⫾ 2.4 77.4 ⫾ 1.6 91.4 ⫾ 3.7
C 68.4 ⫾ 2.0 87.5 ⫾ 5.4 64.6 ⫾ 2.3 87.7 ⫾ 8.0
D 75.7 ⫾ 3.8 91.3 ⫾ 0.5 72.4 ⫾ 8.9 90.1 ⫾ 7.6
E 78.0 ⫾ 6.1 93.6 ⫾ 3.1 70.4 ⫾ 6.0 88.5 ⫾ 4.8
F 78.7 ⫾ 6.3 92.2 ⫾ 5.6 76.5 ⫾ 10.3 90.6 ⫾ 7.4
G 84.3 ⫾ 3.1 94.7 ⫾ 3.8 81.4 ⫾ 3.2 94.0 ⫾ 2.8
H 90.0 ⫾ 1.2 96.9 ⫾ 1.1 84.1 ⫾ 2.4 94.8 ⫾ 2.4
I 84.2 ⫾ 3.1 94.9 ⫾ 1.6 76.2 ⫾ 15.6 92.8 ⫾ 5.9
J 80.3 ⫾ 4.8 93.7 ⫾ 3.0 75.3 ⫾ 5.8 91.1 ⫾ 4.5

Mean ⫾ group SD 80.6 ⫾ 6.1 93.3 ⫾ 2.5 76.7 ⫾ 6.9 91.8 ⫾ 2.9
936 I. J. Radiation Oncology ● Biology ● Physics Volume 51, Number 4, 2001

Table 6. Comparison of the encompassing volume (SUM) of cardiac contractility, which can be substantial in lesions
slow and planning CT scans located adjacent to the heart and major vessels (7). For
Volume of SUM- Volume of SUM- DIBH, additional time is required for analysis of respiratory
slow missed (%) plan missed (%) patterns and coaching, and the technique has to be used at
when 3 planning when 3 slow CTs all stages of the treatment planning and delivery process.
CTs are used are used These steps can double the time required at each stage (10),
A 6.5 9.4 and such an approach may not be feasible in many depart-
B 13.2 14.6 ments.
C 11.4 9.2 We evaluated the feasibility of using the slow CT scan
D 16.1 10.8 procedure to provide a more complete characterization of
E 18.5 7.6
F 14.8 6.3 tumor mobility. The additional time required for the slow
G 19.7 1.7 CT scans was limited, the procedure was well tolerated by
H 24.4 12.8 patients, and the technique can be implemented without the
I 18.0 12.0 requirement for additional equipment. Slow CT scanning
J 14.3 12.2
resulted in the definition of more reproducible, and inevita-
Mean ⫾ group SD 15.7 ⫾ 4.9 9.7 ⫾ 3.8 bly larger, CTVs than were obtained with standard planning
CT scans. Ideally, slow CT scanning should use slice ac-
quisition times that are equal to or greater than the total
length of a single respiratory cycle in order to gain infor-
ysis of data from patients who underwent three sequential rapid
mation on the position of the lesion during the entire respi-
CT scans confirms the low reproducibility of target volumes
generated using such scans. ratory cycle. Incomplete information may result in tumor
There are essentially two approaches toward the problem mobility being underestimated and give rise to systematic
of tumor mobility. First, mobility could be better character- errors in treatment delivery. Although slow CT scans were
ized, and a “mobile” target volume could be generated more reproducible, they failed to capture all mobility. Rea-
based upon all available information on tumor movements. sons for the latter may include mobility that is not captured
Fluoroscopy is currently used for checking the adequacy of by a single scan, variations between respiratory cycles, and
treatment portals in many institutions; however, fluoroscopy variations in contouring. Technical limitations of our CT
is possible only when the tumor can be visualized and scanner prevented us from further prolonging the slice ac-
represents, at best, a crude two-dimensional estimate of quisition time to capture more respiratory cycles, and we
mobility. In addition, the absence of an accurate link be- opted instead to perform three sequential slow CT scans.
tween fluoroscopy and the geometry of the planning CT The use of multiple slow CT scans seems important, be-
scan may lead to inaccurate margins. cause a single slow CT scan captured only a mean of 80%
A second approach would be to control the target motion of the volume enveloped by three slow CT scans.
by cessation of respiratory movements, e.g., DIBH (10) or The additional radiation exposure resulting from a
active breathing control (12). We attempted this approach in single slow CT scan that is limited to the region of a
an earlier patient cohort, but, in the absence of appropriate peripheral lung tumor is low, and the generation of three
equipment, were unable to evaluate this technique in a such slow scans will generally double the overall radia-
satisfactory manner. In contrast to slow CT scans, DIBH is tion exposure in a typical patient. This additional radia-
unable to address the problem of motion resulting from tion exposure is justifiable in patients with Stage I

Table 7. Coverage of the encompassing volume (SUM) of slow and planning CT scans using a single CTV expanded with a 3-mm and
5-mm margin, respectively

Mean coverage of SUM-slow (%) Mean coverage of SUM-plan (%)

Slow ⫹ 3 mm Plan ⫹ 3 mm Plan ⫹ 5 mm Slow ⫹ 3 mm Plan ⫹ 3 mm Plan ⫹ 5 mm

A 98.7 95.5 98.8 100 99.4 100

B 98.4 96.8 99.8 97.3 97.7 99.9
C 88.1 75.1 86.2 87.7 81.4 88.9
D 94.0 88.1 95.2 90.3 92.4 97.9
E 97.4 88.1 96.9 95.5 93.3 99.4
F 94.6 84.7 91.6 97.1 93.6 97.6
G 98.2 93.4 98.6 97.3 96.7 99.4
H 98.6 94.0 97.8 98.3 95.5 98.6
I 97.9 88.4 95.3 96.3 92.8 97.9
J 97.7 88.0 95.6 98.0 93.8 98.0
Mean ⫾ group SD 96.4 ⫾ 3.4% 89.2 ⫾ 6.3 96.1 ⫾ 5.5 95.8 ⫾ 4.8 93.7 ⫾ 5.9 97.8 ⫾ 3.8
 Multiple “slow” CT scans for assessment of tumor mobility ● F. J. LAGERWAARD et al. 937

Table 8. The coverage (absolute and relative) of SUM-slow by a mean single slow or planning CTV with different margins

Absolute volume (cc) Volume relative to SUM-slow

SUM-slow Single slow ⫹ 3 mm Single plan ⫹ 5 mm Slow ⫹ 3 mm Plan ⫹ 5 mm

A 34.5 48.0 56.6 1.39 1.64

B 23.2 32.3 42.9 1.39 1.84
C 41.1 46.0 52.8 1.12 1.25
D 30.9 39.4 52.7 1.28 1.71
E 25.6 34.7 42.6 1.36 1.66
F 55.0 66.7 77.6 1.21 1.41
G 102.5 127.6 144.8 1.24 1.41
H 221.0 268.0 310.3 1.21 1.40
I 42.4 56.8 65.7 1.34 1.55
J 31.5 42.2 54.3 1.34 1.72
Mean ⫾ group SD 1.29 ⫾ 0.09 1.56 ⫾ 0.19

NSCLC. The complete procedure described here requires
approximately 30 – 45 min of CT scan time. As such, a
simplification of the method using a single slow scan
with the addition of a 3-mm margin was investigated.
This margin seemed sufficient to ensure adequate mean
coverage of the SUM-slow volume; however, in 3 pa-
tients with mobile tumors, this was not the case. Such an
approach resulted in an increase of 29% in the irradiated
volume. Only one of our patients had a lower lobe tumor
and, until more data on mobile tumors become available,
we suggest that the use of a single slow scan expanded
with a 3D margin is not advisable. We currently incor-
porate the information from all three slow scans and the
initial planning CT scan into the generation of the “mo-
bile GTV,” which is then expanded by 5 mm to derive the
CTV for treatment. The resulting 3D volume more accu-
rately represents the axis of tumor movement than is
possible with a single planning CT scan with the use of
isotropic margins.
In conclusion, slow CT scanning seems to be a feasible
and practical method with which reliable data on tumor
mobility can be generated for RT planning. Although recent
studies have shown that doses of up to 103 Gy are feasible
(4), a failure to better define the “mobile GTV” may limit
therapeutic gains from dose escalation in medically inoper-
able NSCLC.

REFERENCES
1. Krol AD, Aussems P, Noordijk EM, et al. Local irradiation
alone for peripheral stage I lung cancer: Could we omit the
elective regional nodal irradiation? Int J Radiat Oncol Biol
Phys 1996;34:297–302.
2. Sibley GS. Radiotherapy for patients with medically inoper-
able Stage I non-small cell lung carcinoma: Smaller volumes
and higher doses—a review. Cancer 1998;82:433– 438.
3. Martel MK, Ten Haken RK, Hazuka MB, et al. Estimation of
tumor control probability model parameters from 3-D dose
distributions of non-small cell lung cancer patients. Lung
Cancer 1999;24:31–37.
4. Hayman JA, Martel MK, Ten Haken RK, et al. Dose escala-
tion in non-small cell lung cancer using conformal 3-dimen-
sional radiation therapy: Update of a phase I trial (Abstr).
J Clin Oncol 1999;18:459a.
5. Samson MJ, van Sornsen de Koste JR, de Boer HC, et al. An
analysis of anatomic landmark mobility and setup deviations
in radiotherapy for lung cancer. Int J Radiat Oncol Biol Phys
1999;43:827– 832.
6. de Boer JCJ, van Sörnsen de Koste JR, Senan S, et al.
Analysis and reduction of 3D systematic and random setup
errors during the simulation and treatment of lung cancer
patients with CT-based dose planning. Int J Radiat Oncol Biol
Phys 2001;49:857– 868.
7. Ross CS, Hussey DH, Pennington EC, et al. Analysis of
movement of intrathoracic neoplasms using ultrafast comput-
erized tomography. Int J Radiat Oncol Biol Phys 1990;18:
671– 677.
8. Shimizu S, Shirato H, Kagei K, et al. Impact of respiratory
movement on the computed tomographic images of small lung
tumors in three-dimensional (3D) radiotherapy. Int J Radiat
Oncol Biol Phys 2000;46:1127–1133.
9. Balter JM, Ten Haken RK, Lawrence TS, et al. Uncertainties
in CT-based radiation therapy treatment planning associated
with patient breathing. Int J Radiat Oncol Biol Phys 1996;36:
167–174.
10. Rosenzweig KE, Hanley J, Mah D, et al. The deep inspiration
breath-hold technique in the treatment of inoperable non-
small-cell lung cancer. Int J Radiat Oncol Biol Phys 2000;48:
81– 87.
11. Senan S, van Sornsen de Koste J, Samson M, et al. Evaluation
of a target contouring protocol for 3D conformal radiotherapy
in non-small cell lung cancer. Radiother Oncol 1999;53:247–
255.
12. Wong JW, Sharpe MB, Jaffray DA, et al. The use of active
breathing control (ABC) to reduce margin for breathing mo-
tion. Int J Radiat Oncol Biol Phys 1999;44:911–919.