Analysis of sagittal plane cine magnetic resonance imaging for measurement of pancreatic tumor residual motion during breath hold and evaluation of gating margins used in radiotherapy treatment

In pancreatic radiotherapy, residual tumor motion during treatment increases the risk of toxicity. Cine imaging acquired during magnetic resonance guided radiotherapy (MRgRT) enables real-time treatment gating in response to anatomical motion, which can reduce this risk; however, treatment gating can negatively impact the efficiency of treatment. This study aimed to quantify the extent of residual tumor motion during breath hold and evaluate the appropriateness of the treatment gating margins used in current clinical practice. Cine imaging acquired during pancreatic MRgRT of 11 patients on the ViewRay MRIdian was analyzed. The total duration of treatment analyzed was 12 h 13 min. Improved methods for processing and analyzing cine imaging were developed: breath holds were systematically separated with frequency analysis, residual motion was measured with consideration of both the tracking structure contour and centroid, and residual motion measurements were supported by phantom measurements of image scaling, resolution, and noise. Residual motion was measured at angles 0°, 45°, 90°, and 135° to the superior-inferior (SI) direction. Total residual motion was measured by combining directional measurements. The minimum tracking structure displacement resolvable through cine imaging was found to be 1.5 mm; therefore, residual motion analysis was limited to 1.5 mm spatial resolution. Total residual motion was contained within margins ±1.5, ±3, and ±4.5mm with mean percentage frequencies of 97.0%, 91.1%, and 67.8%. Most residual motion was observed in the SI direction, and significantly more residual motion was measured for the tracking structure contour than the centroid. The results demonstrate that patients are largely able to maintain breath hold positions to within a 3 mm margin, thus provide evidence that supports the use of a 3mm gating margin in clinical practice. Residual motion frequently exceeded 1.5 mm so a reduction in gating margin would have an undesirable impact on treatment efficiency.