A systematic review and meta-analysis of liver tumor position variability during SBRT using various motion management and IGRT strategies

Purpose: To suggest PTV margins for liver SBRT with different motion management strategies based on a systematic review and meta-analysis. Methods: In accordance with Preferred-Reporting-Items-for-Systematic-Reviews-and-Meta-Analyses (PRISMA), a systematic review in PubMed, Embase and Medline databases was performed for liver tumor position variability. From an initial 533 studies published before October 2020, 36 studies were categorized as 18 free-breathing (FB; n(patients) = 401), 9 abdominal compression (AC; n(patients) = 145) and 9 breathhold (BH; n(patients) = 126). A meta-analysis was performed on inter- and intra-fraction position variability to report weighted-mean with 95% confidence interval (CI95) in superior-inferior (SI), left-right (LR) and anterior-posterior (AP) directions. Furthermore, weighted-mean ITV margins were computed for FB (n(studies) = 15, n(patients) = 373) and AC (n(studies) = 6, n(patients) = 97) and PTV margins were computed for FB (n(studies) = 6, n(patients) = 95), AC (n(studies) = 7, n(patients) = 106) and BH (n(studies) = 8, npatients = 133). Results: The FB weighted-mean intra-fraction variability, ITV margins and weighted-standard-deviation in mm were SI-9.7, CI95 = 9.3-10.1, 13.5 +/- 4.9; LR-5.4, CI95 = 5.3-5.6, 7.3 +/- 7.9; and AP-4.2, CI95 = 4.04.4, 6.3 +/- 7.6. The inter-fraction-based results were SI-4.7, CI95 = 4.3-5.1, 5.7 +/- 1.7; LR-1.4, CI95 = 1.11.6, 3.6 +/- 2.7; and AP-2.8, CI95 = 2.5-3.1, 4.8 +/- 2.1. For AC intra-fraction results in mm were SI-1.8, CI95 = 1.6-2.0, 2.6 +/- 1.2; LR-0.7, CI95 = 0.6-0.8, 1.7 +/- 1.5; and AP-0.9, CI95 = 0.8-1.0, 1.9 +/- 1.7. The inter-fraction results were SI-2.6, CI95 = 2.3-3.0, 5.2 +/- 2.9; LR-1.9, CI95 = 1.7-2.1, 4.0 +/- 2.2; and AP-2.9, CI95 = 2.5-3.2, 5.8 +/- 2.7. For BH the inter-fraction variability, and the weighted-mean PTV margins and weighted-standard-deviation in mm were SI-2.4, CI95 = 2.1-2.7, 5.6 +/- 2.9; LR-1.8, CI95 = 1.3-2.2, 5.5 +/- 1.7; and AP-1.4; CI95 = 1.2-1.7, 6.1 +/- 2.1. Conclusion: Our meta-analysis suggests a symmetric weighted-mean PTV margin of 6 mm might be appropriate for BH. For AC and FB, asymmetric PTV margins (weighted-mean margin of 4 mm (AP), 6 mm (SI/LR)) might be appropriate. For FB, if larger (>ITV margin) intra-fraction variability observed, the additional intra- and inter-fraction variability should be accounted in the PTV margin. (C) 2021 The Author(s). Published by Elsevier B.V.

Automated summary

This study provides PTV margin suggestions for liver SBRT with different motion management strategies based on a systematic review and meta-analysis, offering specific margin recommendations for patients under different breathing conditions.