Proportional counter dosimetry and microdosimetry for radiotherapy with multiple pion beams

At the Swiss Institute for Nuclear Research (SIN) cancer patients are irradiated with negatively charged pi mesons using a 60-beam medical pion generator, the Piotron. A low-pressure tissue-equivalent proportional counter was used to measure absorbed dose and microdosimetric spectra. A method was developed to allow discrimination of events from different beam components, i.e., beam contamination (electrons and muons), pions in flight, and stopping pions. Measurements were performed along the axis and at lateral distances off one of these identical pion beams. The marked changes of total microdosimetric spectra with depth in phantom detected in earlier measurements are mainly due to large variations in the dose contributions of the beam components and much less to changes in the shapes of the individual microdosimetric spectra. The single beam measurements were used to calculate three-dimensional distributions of absorbed dose and of dose mean lineal energy, yD, for dynamic patient irradiations. Within the whole target volume yD remains nearly constant when irradiated with all 60 beams, whereas considerable changes were found for irradiations with 31 beams coming from a semicircle. Both size and shape of target volumes influence yD, the maximum values ranging from 30 to 45 keV/micron.     

Evaluation of optimization workflow using design of experiment (DoE) for various field configurations in volumetric-modulated arc therapy

PurposeIn volumetric-modulated arc therapy (VMAT), field configurations such as couch or arc angles are defined manually or using a template. A field configuration is reselected through trial-and-error in the case of undesirable resultant planning. To efficiently plan for desirable quality, configurations should be assessed before dose calculation. Design of experiments (DoE) is an optimization technique that efficiently reveals the influence of inputs on outputs. We developed an original tool using DoE to determine the field configuration selection and evaluated the efficacy of this workflow for clinical practice.MethodsComputed-tomography scans of 17 patients and target structures were acquired retrospectively from a brain tumor treated using a dual-arc VMAT plan. The configurations of the couch, arc, collimator angles, field sizes, and beam energy were determined using DoE. The resultant dose distributions obtained using the DoE-selected configuration were compared with the clinical plan.ResultsThe averaged differences between the DoE and clinical plan for 17 patients of doses to 50% of the planning target volume (PTV-D50%), Brain-D60%, Brain-D30%, Brain stem-D1%, Left eye-D1%, Right eye-D1%, Optic nerve-D1%, and Chiasm-D1% were 0.2 ± 0.5%, −1.0 ± 4.6%, 1.7 ± 3.5%, −2.5 ± 6.7%, −0.2 ± 4.9%, −1.2 ± 3.6%, −2.8 ± 7.3%, and −2.1 ± 5.7%, respectively.ConclusionsOur optimization workflow obtained using DoE for various field configurations provided the same or slightly superior plan quality compared with that created by experts. This process is feasible for clinical practice and will efficiently improve treatment quality while removing the influence of the planner’s experience.     

The functional pectoralis major musculocutaneous island flap in head and neck reconstruction

We describe our experience with the true island pectoralis major musculocutaneous flap in patients with high-volume defects for whom free-tissue transfer is unsuitable. Our operative technique is presented. We have modified the method of making a true island of the pectoralis major musculocutaneous flap on a muscle-free pedicle as first described by Wei et al. in 1984. This maintains maximal donor-site muscle function and facilitates closure of the donor-site defect. We present our results in 24 patients, in whom the flap has proved to be robust and reliable. The flap's advantages in terms of increased pedicle length, wider arc of rotation, decreased pedicle bulk, and improved cosmesis of the reconstruction are discussed.     

Lateral wedge with medial only cardiac shielding (LEMONADE) technique in left chest wall adjuvant radiotherapy

BackgroundThis dosimetric study compared lateral wedge with medial only cardiac shielding (LEMONADE) technique, for left chest wall (LCW) irradiation against three other commonly used techniques.Materials and methodsDosimetric parameters of 22 consecutive LBC patients treated using the P1 (LEMONADE technique) were compared with 3 other virtually reconstructed plans : no cardiac shielding with paired wedges; P2 (paired wedges and medial only Y-direction shielding) and P3 (paired wedges and bilateral Y-direction shielding).ResultsP1 showed better target volume (TV) coverage with the mean 90% isodose coverage of 85.59% ± 5.44 compared to 78.90% ± 8.59 and 74.22% ± 9.50 for P2 and P3, respectively. Compared to no cardiac shielding, for a 4.65% drop in TV coverage the V26Gy of heart dropped from 6.68% to a negligible 0.85% for P1. TV receiving < 30Gy is also significantly lesser for P1 compared to P2 and P3 (5.42% vs 10.64% and 15.8%), whilst there is a small difference of 2.75% between no cardiac shielding and P1.ConclusionWith the improvement in BC survival rate, cardiac toxicity associated with adjuvant irradiation for LBC is a major concern. P1 (LEMONADE) technique has a good compromise between cardiac sparing and target coverage and should suffice for most LCW irradiations. Furthermore, the LEMONADE technique is a simple, reproducible and involves fast planning for cardiac sparing, which is ideal for under-resourced departments with heavy workload.     

Volumetric modulated arc therapy for synchronous bilateral whole breast irradiation – A case study

PurposeThe treatment planning of bilateral breast irradiation (BBI) is a challenging task. The overlapping of tangential fields is usually unavoidable without compromising the target coverage. The purpose of this study was to investigate the technical feasibility and benefits of a single isocentre volumetric modulated arc therapy (VMAT) in BBI.Methods and materialsTwo women with bilateral breast cancer were included in this case study. The first patient (Pat#1) underwent a bilateral breast-conserving surgery and sentinel lymph node biopsy. The second patient (Pat#2) underwent a bilateral ablation and axillary lymph node dissection. Planning target volumes (PTV) and organs at risk were delineated on CT images. VMAT plans were created with four (two for both sides, Pat#1) or two (one for each breast, Pat#2) separate VMAT fields. Subsequently, traditional tangential field plans were generated for each patient and the dosimetric parameters were compared.ResultsThe treatment times of the patients with VMAT were less than 15 min with daily CBCT imaging. When compared to the standard tangential field technique, the VMAT plans improved the PTV dose coverage and dose homogeneity with improved sparing of lungs and heart. With traditional field arrangement, the overlapping of the tangential fields was inevitable without significantly compromising the target coverage, whereas with VMAT the hotspots were avoided. The patients were treated with the VMAT technique and no acute skin toxicity was observed with either of the patients.ConclusionsA single isocentre VMAT technique has been implemented clinically for BBI. With the VMAT techniques, the dose delivery was quick and the hotspots in the field overlapping areas were avoided. The PTV dose coverage was superior in VMAT plans when compared with conventional tangential technique plans.     

THE APPLICATION OF AGE RESPONSE FUNCTIONS TO THE OPTIMIZATION OF TREATMENT SCHEDULES

A computer-based technique is described for calculating the survival of normal and malignant cell populations during and after chemotherapy or radiotherapy. For exponentially growing cells, cell sensitivity as a function of the position in the cell cycle (age response function) is considered and survival calculated by means of a method discussed previously (Hahn, 1966; Hahn & Kallman, 1967). It is shown how the age response function is obtained from experimental data. Two examples of the application of the computer-based technique are given. As one example, the technique is used to 'optimize' the scheduling of fractionated irradiations to differentially kill one cell line over another using as a basis for optimization differences in their age response functions. the second example illustrates the use of the technique to determine the relative advantage of different chemotherapy protocols. Here the survival of cycling and noncycling bone marrow stem cells, and resistant and sensitive malignant cells, is calculated. It is suggested that the technique may have direct relevance for the chemotherapy of some leukemias.     

Breast reconstruction with a transverse abdominal island flap

A rectus abdominis musculocutaneous island flap for breast reconstruction following mastectomy is presented. The vascular anatomy of the abdominal wall has been clinically studied in patients undergoing abdominal lipectomy. Cadaver dissections are shown, demonstrating the anatomy, arc of rotation, and design alternatives of the rectus abdominis flap. The surgical technique is demonstrated and representative patients are shown.     

Photoinhibition of Stem Elongation by Blue and Red Light : Effects on Hydraulic and Cell Wall Properties

The underlying mechanism of photoinhibition of stem elongation by blue (BL) and red light (RL) was studied in etiolated seedlings of pea (Pisum sativum L. cv Alaska). Brief BL irradiations resulted in fast transient inhibition of elongation, while a delayed (lag approximately 60 minutes) but prolonged inhibition was observed after brief RL. Possible changes in the hydraulic and wall properties of the growing cells during photoinhibition were examined. Cell sap osmotic pressure was unaffected by BL and RL, but both irradiations increased turgor pressure by approximately 0.05 megapascal (pressure-probe technique). Cell wall yielding was analyzed by in vivo stress relaxation (pressure-block technique). BL and RL reduced the initial rate of relaxation by 38 and 54%, while the final amount of relaxation was decreased by 48 and 10%, respectively. These results indicate that RL inhibits elongation mainly by lowering the wall yield coefficient, while most of the inhibitory effect of BL was due to an increase of the yield threshold. Mechanical extensibility of cell walls (Instron technique) was decreased by BL and RL, mainly due to a reduction in the plastic component of extensibility. Thus, photoinhibitions of elongation by both BL and RL are achieved through changes in cell wall properties, and are not due to effects on the hydraulic properties of the cell.     

Factors affecting the induction and release of secondary dormancy in Kalanchoë seeds

Abstract. Several short daily R irradiations are required from the first day of incubation on water to induce germination of Kalanchoë seeds. When the same light treatment is given after a prolonged dark incubation period at 20°C, secondary dormancy prevents germination. Factors controlling the induction and breaking of secondary dormancy have been investigated. The induction of secondary dormancy is very temperature dependent. Locally puncturing the seed coat strongly delays it. Secondary dormancy is not induced in the presence of GA₃ during the first 10 d of dark incubation, although this growth substance cannot induce dark germination. Prolonged or cyclic daily R irradiations can relieve secondary dormancy of seeds kept on water, even after a dark period of 20 d. A 24 h treatment at 4°C restores responsiveness to short R exposures of slightly secondarily dormant seeds. The synergism between GA₃ and Pfr in non-dormant Kalanchoë seeds, leading to high effectiveness of even one short FR irradiation, still occurs in seeds made secondarily dormant before transfer to GA₃, but more R or FR irradiations, in combination with GA₃, are required for the release of secondary dormancy. A combination of red light and 6-benzyl-aminopurine is ineffective in removing dormancy.     

A study on conventional IMRT and RapidArc treatment planning techniques for head and neck cancers

AimTo evaluate the performance of volumetric arc modulation with RapidArc against conventional IMRT for head and neck cancers.BackgroundRapidArc is a novel technique that has recently been made available for clinical use. Planning study was done for volumetric arc modulation with RapidArc against conventional IMRT for head and neck cancers.Materials and methodsTen patients with advanced tumors of the nasopharynx, oropharynx, and hypopharynx were selected for the planning comparison study. PTV was delineated for two different dose levels and planning was done by means of simultaneously integrated boost technique. A total dose of 70 Gy was delivered to the boost volume (PTV boost) and 57.7 Gy to the elective PTV (PTV elective) in 35 equal treatment fractions. PTV boost consisted of the gross tumor volume and lymph nodes containing visible macroscopic tumor or biopsy-proven positive lymph nodes, whereas the PTV elective consisted of elective nodal regions. Planning was done for IMRT using 9 fields and RapidArc with single arc, double arc. Beam was equally placed for IMRT plans. Single arc RapidArc plan utilizes full 360° gantry rotation and double arc consists of 2 co-planar arcs of 360° in clockwise and counter clockwise direction. Collimator was rotated from 35 to 45° to cover the entire tumor, which reduced the tongue and groove effect during gantry rotation. All plans were generated with 6 MV X-rays for CLINAC 2100 Linear Accelerator. Calculations were done in the Eclipse treatment planning system (version 8.6) using the AAA algorithm.ResultsDouble arc plans show superior dose homogeneity in PTV compared to a single arc and IMRT 9 field technique. Target coverage was almost similar in all the techniques. The sparing of spinal cord in terms of the maximum dose was better in the double arc technique by 4.5% when compared to the IMRT 9 field and single arc techniques. For healthy tissue, no significant changes were observed between the plans in terms of the mean dose and integral dose. But RapidArc plans showed a reduction in the volume of the healthy tissue irradiated at V_15 Gy (5.81% for single arc and 4.69% for double arc) and V_20 Gy (7.55% for single arc and 5.89% for double arc) dose levels when compared to the 9-Field IMRT technique. For brain stem, maximum dose was similar in all the techniques. The average MU (±SD) needed to deliver the dose of 200 cGy per fraction was 474 ± 80 MU and 447 ± 45 MU for double arc and single arc as against 948 ± 162 MU for the 9-Field IMRT plan. A considerable reduction in maximum dose to the mandible by 6.05% was observed with double arc plan. Double arc shows a reduction in the parotid mean dose when compared with single arc and IMRT plans.ConclusionRapidArc using double arc provided a significant sparing of OARs and healthy tissue without compromising target coverage compared to IMRT. The main disadvantage with IMRT observed was higher monitor units and longer treatment time.     

UV microbeam irradiations of the mitotic spindle I. The UV-microbeam apparatus

Summary We describe the assembly of a UV microbeam microscope based on a Zeiss IM35 inverted microscope. The important UV transmitting elements are standard UV epifluorescence attachments available from Zeiss; the main modification involves fitting an adjustable slit in place of the field diaphragm. We describe how to align and focus the UV source for optimal irradiations. Our current version of this machine is also fitted with a monochromator and using monochromatic UV light, we can reproduceably create Areas of Reduced Birefringence in spindle fibres with ca. 2–3 s irradiations, while continually observing the fibres. The microscope is stable and easy to set up, allowing many consecutive experiments to be done, including multiple irradiations on the one cell. In conjunction with video image processing techniques, the cells can be observed continuously using polarising, Nomarski or other optical systems. Some preliminary observations demonstrating the versatility of the machine are described.Abbrevations ARB areas of reduced birefringence - MT microtubules - UV ultraviolet     

Ribulose bisphosphate carboxylase capacity and chlorophyll content in developing seedlings of Chenopodium rubrum L. growing under light of different qualities and fluence rates

In order to evaluate the aclimation of Chenopodium seedlings to different quantum fluence rates of R and BL, kinetics of Rubisco capacity, Chl content and chloroplast structure were studied. Under monochromatic light photoreceptors are stimulated selectively and their influence on biosynthetis capacities during chloroplast development can be studied.R irradiations saturate Rubisco capacity even at the lowest quantum fluence rates applied, whereas Chl a+b synthesis depends strongly upon fluence rate of R. Under BL irradiations, both Rubisco capacity and Chl content are fluence rate dependent. R irradiations favour Chl b synthesis relative to Chl a, whereas under BL Chl a content is high relative to Chl b. Under R irradiation Pfr is the main photoreceptor involved in regulation of Rubisco capacity whereas under BL a specific BL absorbing photoreceptor may control the response. From the fluence rate dependency under BL irradiations it is concluded that the blue region of the day light spectrum may be the sensor for monitoring fluence rate and causing the characteristic changes in shade and high/low WL adaptation with respect to Rubisco levels in Chenopodium.     

Radiotherapy for the treatment of pituitary adenomas: A dosimetric comparison of three planning techniques

AimOur goal was to compare conformal 3D (C3D) radiotherapy (RT), modulated intensity RT (IMRT), and volumetric modulated arc therapy (VMAT) planning techniques in treating pituitary adenomas.BackgroundRT is important for managing pituitary adenomas. Treatment planning advances allow for higher radiation dosing with less risk of affecting organs at risk (OAR).Materials and methodsWe conducted a 5-year retrospective review of patients with pituitary adenoma treated with external beam radiation therapy (C3D with flattening filter, flattening filter-free [FFF], IMRT, and VMAT). We compared dose-volume histogram data. For OARs, we recorded D2%, maximum, and mean doses. For planning target volume (PTV), we registered V95%, V107%, D95%, D98%, D50%, D2%, minimum dose, conformity index (CI), and homogeneity index (HI).ResultsFifty-eight patients with pituitary adenoma were included. Target-volume coverage was acceptable for all techniques. The HI values were 0.06, IMRT; 0.07, VMAT; 0.08, C3D; and 0.09, C3D FFF (p < 0.0001). VMAT and IMRT provided the best target volume conformity (CI, 0.64 and 0.74, respectively; p < 0.0001). VMAT yielded the lowest doses to the optic pathway, lens, and cochlea. The position of the neck in extreme flexion showed that it helps in planning mainly with VMAT by allowing only one arc to be used and achieving the desired conformity, decreasing the treatment time, while allowing greater protection to the organs of risk using C3D, C3DFFF.ConclusionsOur results confirmed that EBRT in pituitary adenomas using IMRT, VMAT, C3D, C3FFF provide adequate coverage to the target. VMAT with a single arc or incomplete arc had a better compliance with desired dosimetric goals, such as target coverage and normal structures dose constraints, as well as shorter treatment time. Neck extreme flexion may have benefits in treatment planning for better preservation of organs at risk. C3D with extreme neck flexion is an appropriate treatment option when other treatment techniques are not available.     

Uses of the rectus femoris myocutaneous flap.

The rectus femoris myocutaneous flap is quite useful for definitive immediate coverage of complex wounds within its territorial arc. We describe 4 cases to illustrate the capabilities of this flap. The indications for, the anatomy of, and the surgical technique for transfer, as well as the functional sequelae in two nonparaplegic patients are discussed.     

The radiolysis and radioracemization of amino acids on silica surfaces

L-Leucine, deposited on both 1-quartz powder and on a commercial amorphous silica preparation (Syloid 63), has been subjected to irradiation in a 60Co gamma-ray source, and the ensuing radiolysis and radioracemization have been determined gas chromatographically. The radiolysis and radioracemization observed for leucine on 1-quartz were rather similar to those noted for a crystalline L-leucine control. L-Leucine on Syloid 63, however, was vastly more susceptible to radiolysis as compared to the L-leucine control, and radioracemization was also markedly enhanced - each increasing with larger radiation dosage. L-Isovaline showed a similar, but diminished, enhancement of radiolysis sensitivity when adsorbed on the Syloid surface, but underwent no radioracemization whatsoever. The divergent results of the control and quartz-leucine irradiations versus the Syloid-leucine and Syloid-isovaline irradiations are interpreted qualitatively in terms of the surface area parameters of the two silica adsorbents and the amino acid adsorbates.     

Analysis of the EBT3 Gafchromic film irradiated with 6 MV photons and 6 MeV electrons using reflective mode scanners

We explore in our study the effects of electrons and X-rays irradiations on the newest version of the Gafchromic EBT3 film. Experiments are performed using the Varian “TrueBeam 1.6” medical accelerator delivering 6 MV X-ray photons and 6 MeV electron beams as desired. The main interest is to compare the responses of EBT3 films exposed to two separate beams of electrons and photons, for radiation doses ranging up to 500 cGy. The analysis is done on a flatbed EPSON 10000 XL scanner and cross checked on a HP Scanjet 4850 scanner. Both scanners are used in reflection mode taking into account landscape and portrait scanning positions. After thorough verifications, the reflective scanning method can be used on EBT3 as an economic alternative to the transmission method which was also one of the goals of this study. A comparison is also done between single scan configuration including all samples in a single A4 (HP) or A3 (EPSON) format area and multiple scan procedure where each sample is scanned separately on its own. The images analyses are done using the ImageJ software. Results show significant influence of the scanning configuration but no significant differences between electron and photon irradiations for both single and multiple scan configurations. In conclusion, the film provides a reliable relative dose measurement method for electrons and photons irradiations in the medical field applications.     

Light and temperature interaction in the photocontrol of germination of seeds in Ludwigia octovalvis

Summary The germination response of seeds of Ludwigia octovalvis (Jacq.) (=Jussiaea suffruticosa L.; Raven, 1963), to continuous light and to various types of intermittent irradiations is determined at 25, 30, 35 and 40° at different light intensities. At 25 and 40° intermittent irradiations are an effective substitute for continuous ones, while at 30 and 35° no promotion of germination is observed in the intermittent irradiations tested, except if the dark interval between light pulses is reduced to 1 min. Previous results obtained in the photocontrol of germination in this species are confirmed and extended to a variety of light cycles and intensities, indicating that the response to temperature is bimodal unless light is supplied continuously with high intensity, and that germination depends on light intensity more markedly in the temperature region of minimum germination (30–35°). As germination in this species is controlled by the red far-red system, hypothesis to account for the temperature dependence are based on the interaction between temperature and the reactions in which phytochrome is involved.Abbreviations L light - D darkness     

Do alignment thresholds define a critical boundary in long-range detection facilitation with co-linear lines?

Thresholds for line contrast detection (experiment 2) were measured with a two-alternative temporal forced-choice procedure as a function of the spatial position of a vertical target line with regard to two co-linear context lines. The different spatial positions of the target line corresponded to values near the position discrimination threshold (experiment 1) reflecting the just detectable lateral offset, or non-co-linearity, between the context lines which were vertically separated by about 100 minutes of visual arc. Target and context lines were vertically separated by about 30 minutes of arc, had equal contrast polarity in one case, and opposite contrast polarity in the other. Strong line contrast detection facilitation is found at perceptually co-linear target locations. This facilitation decreases noticeably at a horizontal target offset that corresponds to the alignment threshold measured with the context lines. The effects are independent of the relative contrast polarity of target and context and, as shown in a third experiment, also independent of both the relative length or number of lines, and the magnitude of their absolute co-axial separation. This independence seems to hold, provided individual line length and co-axial distance between lines are larger than what appears to be the lower limit of the long-range spatial domain for orientation or contour integration (i.e. 20 minutes of arc), as determined by previous studies. The findings reported here suggest that alignment thresholds are likely to define a critical lateral boundary in long-range detection facilitation with co-linear lines. They support models of contour integration based on interactions between neural mechanisms that integrate local signals of contrast, orientation, and relative position or end-to-end alignment. Such mechanisms may help to explain the formation of representations of virtual contours and object contours in human perception.     

Feasibility of intensity-modulated radiotherapy to treat gastric cancer

AimTo present a proposed gastric cancer intensity-modulated radiotherapy (IMRT) treatment planning protocol for an institution that have not introduced volumetric modulated arc therapy in clinical practice. A secondary aim was to determine the impact of 2DkV set-up corrections on target coverage and organ at risk (OAR).Methods and MaterialsTwenty consecutive patients were treated with a specially-designed non-coplanar 7-field IMRT technique. The isocenter-shift method was used to estimate the impact of 2DkV-based set-up corrections on the original base plan (BP) coverage. An alternative plan was simulated (SP) by taking into account isocenter shifts. The SP and BP were compared using dose-volume histogram (DVH) plots calculated for the internal target volume (ITV) and OARs.ResultsBoth plans delivered a similar mean dose to the ITV (100.32 vs. 100.40%), with no significant differences between the plans in internal target coverage (5.37 vs. 4.96%). Similarly, no significant differences were observed between the maximal dose to the spinal cord (67.70 and 67.09%, respectively) and volume received 50% of the prescribed dose of: the liver (62.11 vs. 59.84%), the right (17.62 vs. 18.58%) and left kidney (29.40 vs. 30.48%). Set-up margins (SM) were computed as 7.80 mm, 10.17 mm and 6.71 mm in the left-right, cranio-caudal and anterior-posterior directions, respectively.ConclusionPresented IMRT protocol (OAR dose constraints with selected SM verified by 2DkV verification) for stomach treatment provided optimal dose distribution for the target and the critical organs. Comparison of DVH for the base and the modified plan (which considered set-up uncertainties) showed no significant differences.     

Dosimetric impact of contrast-enhanced 4d computed tomography for stereotactic body radiation therapy of hepatocelluar carcinoma

BackgroundA purpose of the study was to investigate the dosimetric impact of contrast media on dose calculation using average 4D contrast-enhanced computed tomography (4D-CECT) and delayed 4D-CT (d4D-CT) images caused by CT simulation contrast agents for stereotactic body radiation therapy (SBRT) of liver cases.Materials and methodsFifteen patients of liver SBRT treated using the volumetric modulated arc therapy (VMAT) technique were selected retrospectively. 4D-CECT, and d4D-CT were acquired with the Anzai gating system and GE CT. For all patients, gross target volume (GTV) was contoured on the ten phases after rigid registration of both the contrast and delayed scans and merged to generate internal target volume (ITV) on average CT images. Region of interest (ROI) was drawn on contrast images and then copied to the delayed images after rigid registration of two average CT datasets. The treatment plans were generated for contrast enhanced average CT, delayed average CT and contrast enhanced average CT with electron density of the heart overridden.ResultsNo significant dosimetric difference was observed in plans parameters (mean HU value of the liver, total monitor units, total control points, degree of modulation and average segment area) except mean HU value of the aorta amongst the three arms. All the OARs were evaluated and resulted in statistically insignificant variation (p > 0.05) using one way ANOVA analysis.ConclusionsContrast enhanced 4D-CT is advantageous in accurate delineation of tumors and assessing accurate ITV. The treatment plans generated on average 4D-CECT and average d4D-CT have a clinically insignificant effect on dosimetric parameters.