Image-guided radiation therapy (IGRT) has been changing the field of radiation

oncology for decades in order to address problems arising from inter- and intra- fractional
anatomic variations.1 Evidence has been proven to show substantial variations in shapes,
volumes, and positions of treatment targets, as well as the surrounding tissues,
constituting whats called inter- and intra-fractional motion. Interfraction motion is the
measurement of day-to-day differences in the target position.2 2D imaging techniques
such as MV (megavoltage) x-ray imaging and KV (kilovoltage) x-ray imaging, as well as
MV or KV cone beam CT (CBCT), can be used prior to treatment daily to tackle
interfractional motion of a target. Intrafraction motion is the motion of the target volume
measured during the radiation treatment.2 Real-time tracking methods can be utilized
during treatment delivery to minimize the effect of such target motion; this ensures
delivery of the prescription dose to the target volume at all times. However, most
facilities do not have access to real-time tracking methods so intrafraction motion in this
case can be visualized by 2D x-ray images or CBCTs performed prior to treatment and
right after treatment. Both types of motion can impact the outcomes of treatment
significantly and under-dosing of the target, as well as over-dosing of the organs at risk,
can occur.3 Target volume motion from either inter- or intra-fraction motion can arise
from body shift or rotation, weight loss, tumor motion/shrinkage, patient respirations, and
changes in surrounding anatomical structures or nearby organ filing.1 Image guided
radiation therapy is becoming standard of care, especially for tumor sites that have a high
probability of movement due to breathing or surrounding anatomical organ filling (gas,
food, or stool) as well as changes due to radiation tumor response and shrinkage.
The number one example for both inter- and intra-fractional motion is radiation
treatment that targets the prostate. It is easy to see from figure 1, how the prostate can be
positioned in the pelvis differently every single day and this placement is often dictated
by the size of the bladder and rectum from day to day. If a facility did not have the
capabilities to perform a CBCT daily, to align to the planning CT prior to treatment, it is
easy to see how far off one can be day to day in the treatment of prostate cancer. Figure
one is a good example of interfractional motion. Figure 2 displays intrafraction motion
of the prostate that can be seen pre-treatment and post-treatment; one can see the
displacement of the prostate seeds from each image as well as the measured shifts in 3
planes before and after treatment. If prostate motion is not taken into account at the time
of simulation, and we do not provide a big enough margin around the prostate during
treatment planning, the prostate could be get under dosed due to movement out of the
PTV volume/beam path. Use of a rectal balloon placed daily for treatment can not only
help decrease rectal wall irradiation by pushing the posterior wall away from the prostate
but it can also can help in limiting the motion of the prostate during treatment (this would
help with intrafraction motion). However, balloon placement can be placed differently
due to air or stool in the rectum which in turn can now add to interfraction motion
(motion witnessed day-to-day). Aside from rectal and bladder volume changes, patient
respiration can also lead to intrafraction motion of the prostate, especially in the
anterior/posterior direction.3 This same study stated that the contraction of pelvic floor
muscles can also contribute to intrafraction motion, especially when the patient is
fighting off incontinence.

Figure 1. Visualization of the effect of tumor motion, setup error, and delineation error on
the dose delivery in radiotherapy.4

Figure 2. Visualization of intrafraction motion by way of 2D, AP x-rays performed pretreatment and post-treatment.2

A comparison I made to better describe interfractional motion is how a persons

jeans may fit day to day. I do not wear jeans or dress pants often (oh the joys of scrubs!)
but my jeans seem to fit differently day to day. Someone may attempt to lose weight in
order to fit in their jeans better so they can go from tight to lose; the changes in how a
pair of jeans fit can be determined by food and water intake each day as well as increased
or decreased physical activity. When targeting a mass with radiation therapy, especially a
mass in the lung, we can often times see shrinkage of this volume and this would
correlate to interfractional motion from day to day. Weight loss over the course of ones
radiation treatment course, that changes the placement of the target volume from day to
day, also correlates to my example about jeans fitting after weight loss.

A comparison I made to better describe intrafractional motion is in the act of

increased heart rate during a run. As my heart rate increases during a 3 mile run, I witness
changes in my breathing patterns, muscle fatigue, and increased perspiration. My
breathing is slow and normal prior to a run and I do not experience muscle soreness or
perspiration. The more my heart rate goes up when I start to run and change my running
speed, the more likely I am to experience muscle soreness, dehydration, and faster
breathing patterns. In radiation therapy delivery, we can test the placement of the target
volume prior to treatment with the use of an x-ray, and then image following treatment to
see the difference in the placement of the target volume; the patient can progressively get
more uncomfortable on the hard table and increased respirations are sometimes witnessed
from anxiety after the therapists leave the room, all of which can cause the target volume
to move.

1. Li G, Mageras GS, Dong L, Mohan R. Image-guided radiation therapy. In: Khan FM,
Gerbi BJ. Treatment Planning in Radiation Oncology. 3rd ed. Philadelphia, PA:
Lippincott Williams and Wilkins, a Wolters Kluwer business; 2012: 229-250.
2. Su Z. Prostate motion and its impact on proton dosimetry. (PowerPoint). University of
Florida Proton Therapy Institute. www.medicaldosimetry.org/pub/398353e9-d714-5125b9dfec9aeded. Accessed March 27, 2016.
3. Huang E, Dong L, Chandra A, et al. Intrafraction prostate motion during IMRT for
prostate cancer. Int J Radiat Oncol Biol Phys. 2002; 53(1):261-268. doi: 10.1016/S03603016(02)02738-4.
4. Herk MV, Remeijer P, Rasch C, Lebesque JV. The probability of correct target
dosage: dose-population histograms for deriving treatment margins in radiotherapy. Int J
Radiat Oncol Biol Phys. 2000; 47(4):1121-1135. doi: 10.1016/S0360-3016(00)00518-6