Journal of Medical Imaging and Radiation Sciences 56 (2025) 101860

www.elsevier.com/locate/jmir
Systematic Review

The volumetric and dosimetric impacts of respiratory motion management

in lung SBRT: A systematic review from 2019-2024
Bonan Zhang, Laure Marignol and Maeve Kearney∗
Applied Radiation Therapy Trinity, Discipline of Radiation Therapy, School of Medicine, Trinity College, Dublin, Ireland

and lung protection, with tracking showing the greatest reduction in

ABSTRACT
target volume.
Background: The efficacy of Stereotactic Body Radiation Therapy
(SBRT) is contingent upon accurately accounting for respiratory mo- Conclusion: Patient selection is crucial when determining the most
tion. Although several methods have been developed, the extent of appropriate respiratory motion management approach. Establishing a
volumetric and dosimetric benefit, as well as the criteria for selecting consensus on planning objective is necessary for accurate data evalua-
appropriate methods for individual patients remain unclear. tion. Further research is required to refine these techniques and explore
innovative technologies that could enhance the effectiveness and safety
Purpose: To assess the extent of target volume reduction and lung of respiratory motion management in lung SBRT.
dose reduction in lung cancer patients treated with SBRT, comparing
active versus non-active respiratory motion management approaches.
Materials and Methods: A comprehensive search was conducted RÉSUMÉ
across multiple databases, including MEDLINE Ovid (PubMed), Contexte: L’efficacité de la radiothérapie corporelle stéréotaxique
EMBASE, and the Web of Science Core Collection, covering the pe- (SBRT) repose sur une prise en compte précise du mouvement respi-
riod from 2019 to 2024. The Preferred Reporting Items for System- ratoire. Bien que plusieurs méthodes aient été développées, l’étendue
atic Reviews and Meta-Analyses (PRISMA) guidelines were followed des avantages volumétriques et dosimétriques, ainsi que les critères de
to identify studies relevant to respiratory motion management in lung sélection des méthodes appropriées pour chaque patient, restent incer-
SBRT. Data extracted included target volume delineation, target vol- tains.
ume sizes, and lung doses reported.
Objectif: Évaluer l’étendue de la réduction du volume cible et de la
Results: The review included 14 studies involving 273 patients, which dose pulmonaire chez les patients atteints de cancer du poumon traités
examined both active and non-active respiratory motion management par SBRT, en comparant les approches actives et non actives de gestion
approaches. Active respiratory motion management approaches were du mouvement respiratoire.
associated with significant reduced target volume sizes and lung doses
compared to non-active approaches. Tracking and deep inspiration Matériels et Méthodes: Une recherche approfondie a été menée dans
breath-hold demonstrated superiority in reduction in target volume plusieurs bases de données, notamment MEDLINE Ovid (PubMed),

Abbreviations: 3DCT, Three-dimensional computed tomography; 4DCT, Four-dimensional computed tomography; ABC, Active breathing control; AIP,
Average intensity projection; AP, Anterior-posterior; BH, Breath-hold; CBCT, Cone beam computed tomography; COVID, Coronavirus disease; CT, Computed
tomography; CTV, Clinical target volume; DEBH, Deep expiration breath-hold; DIBH, Deep inspiration breath-hold; DMLC, Dynamic multi-leaf collimator;
EMT, Electromagnetic transponder; ESTRO, European SocieTy for Radiotherapy & Oncology; GTV, Gross tumour volume; GW, Gating window; iGTV, Internal
gross tumour volume; ITV, Internal target volume; LINAC, Linear accelerator; LR, Left-right; MINORS, Methodological Index for Non-randomised Studies; MIP,
Maximum intensity projection; MLC, Multi-leaf collimator; MLD, Mean lung dose; MRI, Magnetic resonance imaging; NSCLC, Non-small cell lung cancer; NTCP,
Normal tissue complication probability; OAR, Organs at risk; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; PTV, Planning target
volume; ROI, Region of interest; RP, Radiation-induced pneumonitis; SABR, Stereotactic ablative radiotherapy; SBRT, Stereotactic body radiation therapy; SI,
Superior-inferior.
Contributors: All authors contributed to the conception or design of the work, the acquisition, analysis, or interpretation of the data. All authors were involved
in drafting and commenting on the paper and have approved the final version.
Funding: This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Competing interests: All authors declare no conflict of interest.
Ethical approval: Not required for this article type.
∗ Corresponding author.

E-mail address: [email protected] (M. Kearney).

1939-8654/$ - see front matter © 2025 Published by Elsevier Inc. on behalf of Canadian Association of Medical Radiation Technologists. This is an open access
article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)
https://doi.org/10.1016/j.jmir.2025.101860
EMBASE et la Web of Science Core Collection, couvrant la période actives. Le suivi du mouvement et la rétention inspiratoire profonde
de 2019 à 2024. Les directives PRISMA (Preferred Reporting Items ont démontré une supériorité en matière de réduction du volume cible
for Systematic Reviews and Meta-Analyses) ont été suivies pour iden- et de protection pulmonaire, le suivi du mouvement montrant la ré-
tifier les études pertinentes sur la gestion du mouvement respiratoire duction la plus importante du volume cible.
en SBRT pour les poumons. Les données extraites incluaient la délim-
Conclusion: La sélection des patients est cruciale pour déterminer
itation des volumes cibles, les tailles des volumes cibles et les doses
l’approche de gestion du mouvement respiratoire la plus appropriée.
pulmonaires rapportées.
Il est nécessaire d’établir un consensus sur les objectifs de planification
Résultats: La revue comprenait 14 études portant sur 273 patients, pour une évaluation précise des données. Des recherches supplémen-
examinant des approches actives et non actives de gestion du mou- taires sont requises pour affiner ces techniques et explorer des tech-
vement respiratoire. Les approches actives de gestion du mouvement nologies innovantes susceptibles d’améliorer l’efficacité et la sécurité
respiratoire étaient associées à une réduction significative des tailles des de la gestion du mouvement respiratoire en SBRT pour les poumons.
volumes cibles et des doses pulmonaires par rapport aux approches non

Keywords: Respiratory motion management; Lung neoplasms; Stereotactic body radiation therapy

Introduction and increased risks from invasive implant procedures are the
challenges [20,25-29].
Lung cancer remains the leading cause of cancer death world-
While there is mounting evidence that reparatory motion
wide, with 2.2 million new cases and 1.8 million deaths in 2020
management can help protect tissue and reduce the risk of
[1]. Stereotactic Body Radiation Therapy (SBRT) is a recom-
radiation-induced injuries like pneumonitis and fibrosis in lung
mended treatment for inoperable early-stage lung cancer and
cancer patients treated with SBRT [25,30-32], no clear con-
metastases, offering excellent tumour control by delivering high
sensus exists on which approach provides the most benefit to
doses while sparing normal tissues [2,3]. Due to the high dose
patients. This review evaluates the target volume definition
per fraction, it is critical to address various geometric uncertain-
method together with volumetric and dosimetric outcomes re-
ties, particularly respiratory motion which can reach up to 30
ported in the literature following respiratory motion manage-
mm, in order to avoid underdosing the tumour and overexpos-
ment in lung SBRT. We describe variations in target volume
ing normal lung tissues [4-8].
and lung dose reduction according to the approaches used, and
Respiratory motion management is essential in lung SBRT
suggest that active approaches are beneficial for patients.
and can be implemented using either a non-active or active ap-
proach. In the non-active approach, the patient breathes freely,
and tumour motion during the breathing cycle is managed us- Materials and methods
ing the Internal Target Volume (ITV) [9]. This concept uses
the four-dimensional computed tomography (4DCT) to cap- Search strategy for identification of studies
ture full tumour motion [10]. This method involves delineating MEDLINE Ovid (PubMed), EMBASE, and Web of Sci-
the Gross Tumour Volume (GTV) at every breathing phase and ence Core Collection were searched for articles reporting
merging them to create the ITV [11]. While effective, it is time- dosimetry in lung SBRT, using terms like “SBRT”, “SABR”,
consuming and alternative techniques like Maximum Intensity “stereotactic body radiation therapy”, “lung cancer”, “breath
Projection (MIP) and Average Intensity Projection (AIP) have hold”, “gating”, “tracking” and “free breathing”. The search
been explored to improve efficiency [12,13]. However, an ITV covered articles published from January 1, 2019, to February
can significantly increase the volume of normal tissue irradiated 10, 2024. Search words/MeSH terms and the number of stud-
because it encompasses the entire range of motion a tumour ies found can be found in the supplementary material.
might have during treatment, essentially including surround-
ing healthy tissue unnecessarily, leading to a larger treatment
volume and potentially increased side effects on normal tissues Study eligibility criteria
[14]. Following PRISMA guidelines (Fig. 1), 358 records were
In contrast, active respiratory motion management aims to identified, and 113 duplicates were removed. Screening of 245
control patient’s breathing by restricting respiratory motion ei- articles by title and abstract excluded those on non-lung can-
ther at the inspiratory or expiratory phase during breath-hold cer tumours, phantom studies, case studies, reviews, surveys,
(BH) treatment, or adapting dose delivery to a specific patient’s non-dosimetry articles, unrelated respiratory motion manage-
breathing phase with the introduction of respiratory gating or ment, technical notes, guideline articles, conference abstracts,
real-time tumour tracking [15]. These approaches, however, paediatric patients, cohorts of fewer than five patients, and non-
can suffer from poor patient compliance and extended treat- photon modalities. Non-photon modalities were excluded due
ment time [16-24]. In the case of tumour tracking, high costs to differences in planning definitions and beam characteristics.

2 B. Zhang, L. Marignol and M. Kearney / Journal of Medical Imaging and Radiation Sciences 56 (2025) 101860
 Fig. 1. PRISMA flow diagram.

Additionally, the limited number of studies on proton beam metastases, where respiratory motion management was used in
therapy made a comparison between photon- and non-photon- SBRT planning or delivery.
based radiation therapy unfeasible. Including both photon and
non-photon studies in the same analysis could skew the results. Type of interventions
Only full-text articles in English were considered. Eligible stud-
ies reported dosimetry or target volume definition using respi- Lung SBRT studies using either active or non-active respi-
ratory motion management in lung SBRT. ratory motion management approaches.

Type of outcomes
Type of participants
Eligible studies reported target volume delineation ap-
Participants over 18 years old with pathologically confirmed proaches, target volumes, or lung doses from SBRT treatment
early-stage lung primary cancer (Stage I-II) or solitary lung or planning for lung cancer management.

B. Zhang, L. Marignol and M. Kearney / Journal of Medical Imaging and Radiation Sciences 56 (2025) 101860 3
Data extraction Table 1
Characteristics of patient cohort.
Data extracted from each eligible study included author,
Variable
publication year, number of patients and lesions, tumour lo-
Patients 273
cations, fractionation, type of respiratory motion management
Lesions 280∗
approach used, dataset for target volume delineation, reported Diagnosis
target volumes size, and lung doses reported. Studies were cat- Primary lung cancer 186
egorised by respiratory motion management type: non-active Metastases 84
(ITV-based approach) or active (breath hold, gating, and track- Not specified 10
Tumour location
ing). Information on target volume size and lung doses was ex-
Upper 82
tracted where available. Middle 16
Lower 140
Not specified 42
Data analysis ∗ 7 patients have 2 lesions.
The studies reviewed were equally split between prospective
and retrospective, with predominantly descriptive data analysis.
difference between these approaches is the GTV definition.
The analysis focused on target volume delineation and sizes,
Nine studies [30,31,34,36-40,42] generated an ITV by merg-
as well as dosimetric parameters such as V5whole /V5ipsi (per-
ing GTVs from all 4DCT phases, while three [30,31,38] also
centage of the whole/ipsilateral lung receiving at least 5Gy),
explored phase-gating, merging GTVs on specific phases (e.g.,
and lung V20whole /V20ipsi (percentage of the whole/ipsilateral
30–70 % phases by Cheng et al. [38] and 40–60 % phases by
lung receiving at least 20Gy). Average target volume sizes and
Prunaretty et al. [31]). Two other studies [35,41] used the max-
lung doses, termed “average PTV volumes” and “average lung
imum intensity projection (MIP) dataset to generate an ITV.
doses,” were compared across different respiratory motion man-
The breath-hold (BH) approach was documented in seven
agement approaches and lobar locations.
studies [34-37,42-44]. The GTV was delineated on the deep
inspiration breath-hold (DIBH) 3DCT dataset in inspiration
Quality assessment BH technique studies [34-37,42,43], with one study [37] us-
ing three DIBH CT datasets. Expiration BH technique studies
The quality of the studies was assessed using the Method- [43,44] delineated the GTV on end expiration BH CT dataset.
ological Index for Non-randomized Studies (MINORS) as- Four studies [6,31,34,39] explored the tracking approach.
sessment tool, which comprises 12 items appropriate for non- Matsuo et al. [6] co-registered GTVs from end-of-exhaled BH
randomized studies [33]. Each item is scored from 0 to 2, with 0 CT and 4DCT, while Prunaretty et al. [31] delineated GTVs
indicating not reported, 1 indicating reported but inadequate, for each 4DCT phase. Booth et al. [39] used the end-of-exhale
and 2 indicating reported and adequate. The ideal score is 16 4DCT phase for GTV delineation, and one study [34] used
for non-comparative and 24 for comparative studies. both end-of-inhale and end-of-exhale phases.
PTV definition varied across studies, PTV margins was
Results added on different target volumes, varied from iGTV to ITV.
Eleven studies used a uniform PTV expansion of 3 or 5 mm
Fourteen studies, encompassing 273 patients with early- [30,31,34-40,42,44], while others used non-uniform expan-
stage primary lung cancer or solitary lung metastases, were in- sions.
cluded in this review. These patients under went SBRT treat-
ment or planning using non-active or active respiratory motion
management approaches. Dose prescriptions varied from 34 to PTV volumes and reduction
60 Gy in 3 to 8 fractions. The characteristics of the studies and Tables 3 and 4 summarises average and range PTV vol-
patient cohorts are detailed in Tables 1 and 2. umes. The reported average PTV volume was 36.35 cm3 (1.76–
112.50 cm3 ) in non-active plans, 26.26 cm3 (3.28–78.9 cm3 )
Target volume definition in breath-hold plans, 30.18 cm3 (1.8–89.9 cm3 ) for phase-
gated plans, and 12.48 cm3 (1.4–148.0 cm3 ) for tracking tech-
The target volume delineation approaches extracted from nique. Nine studies directly compared PTV volumes between
the included studies are documented in Table 2, where avail- active approach and non-active approach in the same patient
able. group.
Five studies compared PTV volumes between DIBH and
non-active approaches in the same patient group, reported an
Target volume delineation
average reduction of 23.9 % (11.1–66.4 %) in PTV volume.
The ITV technique was employed in eleven stud- One study [35] found a significant reduction (p < 0.01) in
ies [30,31,34-42], including both non-active motion- PTV volume in DIBH plans (median 23.46 cm3 ) compared to
encompassing and phase-gating approaches. The primary non-active plans (median 32.28 cm3 ). Another study [34] re-

4 B. Zhang, L. Marignol and M. Kearney / Journal of Medical Imaging and Radiation Sciences 56 (2025) 101860
 Table 2
Demographics, target delineation and dosimetric data found in studies on respiratory motion management in lung SBRT.
Author, year No. of Diagnosis (no. Fractionation, Gy / Location of Respiratory Dataset used for Target Volume PTV Volumes Lung V5 Lung V20
Patients lesions) fraction, # tumours (no. Motion Delineation Definition
lesions) Management
Li et al., 20 Early-stage lung 48/4 Upper (8) DIBH DIBH CT PTV=GTV+4mm Median 6.65 cm3 Mean 4.82cc Mean 0.86cc
B. Zhang, L. Marignol and M. Kearney / Journal of Medical Imaging and Radiation Sciences 56 (2025) 101860

2023 primary (5) Middle (3) End exp BH End exp BH CT (AP & LR) & 5mm (3.28–40 cm3 ) Mean 5.14cc Mean 1.01cc
Metastases (15) Lower (9) Alternate BH DIBH & end exp (SI) Mean 5.44cc Mean 0.84cc
BH CT
Holla et al., 23 Early-stage 45/5 Upper (13) Tracking End of exhale & PTV=ITV+3mm Mean 41.66cm3 Mean 17.8 % Mean 3.9 %
2021 NSCLC (9) end of inhale CT
Metastases (14) DIBH DIBH CT PTV=ITV+5mm Mean 52.54cm3 Mean 18.8 % Mean 4.5 %
Non-active 4DCT ITV-based PTV=ITV+5mm Mean 79.97 cm3 Mean 20.4 % Mean 4.7 %
Middle (4) Tracking End of exhale & PTV=ITV+3mm Mean 27.13 cm3 Mean 17.8 % Mean 3.3 %
end of inhale CT
DIBH DIBH CT PTV=ITV+5mm Mean 46.89 cm3 Mean 18.2 % Mean 3.2 %
Non-active 4DCT ITV-based PTV=ITV+5mm Mean 71.1 cm3 Mean 19.2 % Mean 4.4 %
Lower (6) Tracking End of exhale & PTV=ITV+3mm Mean 17.99 cm3 Mean 31.4 % Mean 6.3 %
end of inhale CT
DIBH DIBH CT PTV=ITV+5mm Mean 26.30 cm3 Mean 27.1 % Mean 5.7 %
Non-active 4DCT ITV-based PTV=ITV+5mm Mean 58.69 cm3 Mean 29.8 % Mean 5.9 %
Mokeset et 13 Early-stage 45/3 N/S (16) Non-active 3DCT+4DCT ITV=union of GTVs Mean 32.28 cm3 N/S Median 3.7 %
al., 2022 NSCLC (16)# MIP on 10 phases (13.64–72.89 cm3 ) (0.47 %-6.70 %)
PTV=ITV+3–5mm
DIBH DIBH CT CTV=GTV+5mm Mean 23.46 cm3 N/S Median 2.17 %
PTV=CTV+5mm (9.06–61.52 cm3 ) (0.45 %-15.87 %)
Jaccard et al., 7 Early-stage lung 60/8 Left upper (1) Non-active 4DCT ITV-based 11.5 cm3
For non-active ITV: N/S N/S
2019 primary (7) 60/8 Left upper (1) DIBH DIBH CT ITV=union of GTVs 9.1 cm3 15.6 %∗ 3.6 %∗
Non-active 4DCT ITV-based on 10 phases 13.2 cm3 27.1 %∗ 7.5 %∗
60/5 Left lower (1) Non-active 4DCT ITV-based PTV=ITV+5mm 24.7 cm3 N/S N/S
60/8 Left lower (1) Non-active 4DCT ITV-based For DIBH: 77.4 cm3 N/S N/S
60/3 Right lower (1) DIBH DIBH CT PTV=GTV + 5mm 11.5 cm3 18.7 %∗ 3.8 %∗
Non-active 4DCT ITV-based 20.9 cm3 23.4 %∗ 5.8 %∗
60/3 Right upper (1) DIBH DIBH CT 7.1 cm3 11.8 %∗ 3.1 %∗
Non-active 4DCT ITV-based 10.1 cm3 17.4 %∗ 5.4 %∗
60/5 Left upper (1) DIBH DIBH CT 13.2 cm3 16.2 %∗ 3.2 %∗
Non-active 4DCT ITV-based 18.7 cm3 19.0 %∗ 4.5 %∗
Lee et al., 46 Early-stage 48/6 Right upper (14) Non-active 4DCT ITV-based ITV=union of GTVs Mean 23.5 cm3 N/S N/S
2022 NSCLC (23)# 48/4 Right middle (2) on 10 phases (4.0–99.5 cm3 )
Metastases (27)# 50/5 Right lower (12) PTV=ITV+5mm
55/5 Left upper (8) DIBH DIBH CT PTV=Integrated Mean 23.2 cm3 N/S N/S
60/5 Left lower (14) GTV of multiple (4.2–57.8 cm3 )
CT+5mm
(continued on next page)
5
6

Table 2 (continued)

Author, year No. of Diagnosis (no. Fractionation, Gy / Location of Respiratory Dataset used for Target Volume PTV Volumes Lung V5 Lung V20
B. Zhang, L. Marignol and M. Kearney / Journal of Medical Imaging and Radiation Sciences 56 (2025) 101860

Patients lesions) fraction, # tumours (no. Motion Delineation Definition

lesions) Management

Miura et al., 10 Early-stage 48/4 Left upper (1) End exp BH End exp BH CT ITV=GTV+3mm 35.3 cm3 14.2 % ± 3.1 % 3.8 % ± 1.0 %
2020 NSCLC (10) Right upper (1) PTV=ITV+5mm 30.5 cm3 (mean ± SD) (mean ± SD)
Left lower (1) 36.8 cm3 (10.0–19.3 %) (2.2–5.3 %)
Right middle (1) 22.0 cm3
Left upper (1) 57.4 cm3
Right upper (1) 32.8 cm3
Right lower (1) 18.9 cm3
Right middle (1) 19.2 cm3
Left upper (1) 25.4 cm3
Right lower (1) 47.8 cm3
Cheng et al., 15 Early-stage 48/4 Upper (4) Phase gating 30–70 % phase ITV=union of GTVs Mean 21.6 cm3 Mean 14.1 % Mean 3.1 %
2023 NSCLC (9) 54/3 Lower (11) CT on 30–70 % phase (7.9–56.5 cm3 ) (8.5–19.7 %) (1.6–6.0 %)
Metastases (6) CT
PTV=ITV+3mm
Non-active 4DCT ITV-based ITV=union of GTVs Mean 40.1 cm3 Mean 16.1 % Mean 4.7 %
on 10 phases CT (14.7–112.5 cm3 ) (8.9–27.3 %) (2.2 %-8.7 %)
PTV=ITV+5mm
Booth et al., 17 Early-stage 48/4 Left upper (3) MLC tracking End-exhale phase PTV=GTV+5mm 18.6 ± 11.4 cm3 N/S N/S
2021 NSCLC (7) 50/4 Left lower (4) CT (mean ± SD)
Metastases (10) Right upper (3) (3.9–39.6 cm3 )
Right middle (1) Non-active 4DCT ITV-based ITV=union of GTVs 25.0 ± 14.2 cm3 N/S N/S
Right lower (6) on 10 phases CT (mean ± SD)
PT =ITV+5mm (5.0–53.9 cm3 )
Matsuo et al., 48 Early-stage 50/4 Upper or middle Dynamic tumour End-exhale phase CTV=GTV+3mm Mean 49.9 cm3 Median 5.0 % Median 3.8 %
2022 NSCLC (42) (4) tracking CT & 4DCT ITV=CTV+margin (16–148 cm3 ) (1.0–10.7 %) (1.6–13.6 %)
Metastases (6) Lower (44) (N/S)
PTV= TV+5–8mm
Saglam et al., 25 Early-stage 50/4 Left upper (8) Non-active 4DCT ITV-based ITV=union of GTVs Mean 16.39 cm3 Median 11.5 % Median 0.4 %
2023 NSCLC (25) Left lower (2) on 10 phases CT (1.76–37.84 cm3 ) (8.09–13.23 %) (0.10–0.85 %)
Right upper (7) PTV=ITV+5mm
Right lower (8)
(continued on next page)
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Table 2 (continued)

Author, year No. of Diagnosis (no. Fractionation, Gy / Location of Respiratory Dataset used for Target Volume PTV Volumes Lung V5 Lung V20
Patients lesions) fraction, # tumours (no. Motion Delineation Definition
lesions) Management

Kraus et al., 14 Early-stage lung 45/3 Right lower Phase-gating 40–60 % phase For 40–60 % 43.3 cm3 N/S 6.5 %∗
2021 primary (8) peripheral (1) Non-active CT phase-gating: 59.5 cm3 N/S 7.5 %∗
Metastases (6) Left lower Phase-gating 4DCT ITV-based ITV=union of GTVs 35.0 cm3 N/S 5.1 %∗
peripheral (1) Non-active 40–60 % phase on 40–60 % % phase 31.7 cm3 N/S 5.7 %∗
Left upper Phase-gating CT CT 11.6 cm3 N/S 4.2 %∗
peripheral (1) Non-active 4DCT ITV-based PTV=ITV+5mm 34.1 cm3 N/S 9.5 %∗
Right lower Phase-gating 40–60 % phase For 20–40 % 48.8 cm3 N/S 8.2 %∗
peripheral (1) Phase-gating CT phase-gating: 59.7 cm3 N/S 8.0 %∗
Phase-gating 4DCT ITV-based ITV=union of GTVs 59.3 cm3 N/S 8.8 %∗
Non-active 40–60 % phase on 20–40 % phase 79.8 cm3 N/S 10.1 %∗
CT CT
20–40 % phase PTV=ITV+5mm
CT For 20–70 %
20–70 % phase phase-gating:
CT ITV=union of GTVs
4DCT ITV-based on 20–70 % phase
CT
PTV=ITV+5mm
For non-active ITV:
ITV=union of GTVs
on 10 phases CT
PTV=ITV+5mm
(continued on next page)
7
 Table 2 (continued)

Author, year No. of Diagnosis (no. Fractionation, Gy / Location of Respiratory Dataset used for Target Volume PTV Volumes Lung V5 Lung V20
Patients lesions) fraction, # tumours (no. Motion Delineation Definition
8

lesions) Management

Right hilar central Phase-gating 40–60 % phase 14.9 cm3 N/S 2.0 %∗
(1) CT
Phase-gating 20–40 % phase 15.4 cm3 N/S 1.9 %∗
CT
Phase-gating 20–70 % phase 15.9 cm3 N/S 2.1 %∗
CT
Non-active 4DCT ITV-based 17.3 cm3 N/S 2.2 %∗
B. Zhang, L. Marignol and M. Kearney / Journal of Medical Imaging and Radiation Sciences 56 (2025) 101860

Left hilar central Phase-gating 40–60 % phase 36.1 cm3 N/S 11.0 %∗
(1) CT
Phase-gating 20–40 % phase 38.1 cm3 N/S 11.6 %∗
CT
Phase-gating 20–70 % phase 42.2 cm3 N/S 14.1 %∗
CT
Non-active 4DCT ITV-based 48.3 cm3 N/S 17.5 %∗
Right hilar central Phase-gating 40–60 % phase 28.2 cm3 N/S 15.1 %∗
(1) CT
Phase-gating 20–40 % phase 29.4 cm3 N/S 15.3 % %∗
CT
Phase-gating 20–70 % phase 34.7 cm3 N/S 17.5 %∗
CT
Non-active 4DCT ITV-based 41.8 cm3 N/S 22.9 %∗
Left hilar central Phase-gating 40–60 % phase 83.1 cm3 N/S 16.7 %∗
(1) CT
Phase-gating 20–40 % phase 80.4 cm3 N/S 16.6 %∗
CT
Phase-gating 20–70 % phase 89.9 cm3 N/S 17.8 %∗
CT
Non-active 4DCT ITV-based 99.2 cm3 N/S 19.0 %∗
Right hilar central Phase-gating 40–60 % phase 71.1 cm3 N/S 12.9 %∗
(1) CT
Phase-gating 20–40 % phase 61.7 cm3 N/S 12.5 %∗
CT
Phase-gating 20–70 % phase 75.7 cm3 N/S 14.3 %∗
CT
Non-active 4DCT ITV-based 91.6 cm3 N/S 14.5 %∗
Right hilar central Phase-gating 40–60 % phase 62.9 cm3 N/S 14.2 %∗
(1) CT
Non-active 4DCT ITV-based 93.5 cm3 N/S 17.2 %∗
Left hilar central Phase-gating 40–60 % phase 40.7 cm3 N/S 4.2 %∗
(1) CT
Non-active 4DCT ITV-based 45.0 cm3 N/S 4.5 %∗
Left hilar central Phase-gating 40–60 % phase 16.4 cm3 N/S 3.7 %∗
(1) CT
Non-active 4DCT ITV-based 18.2 cm3 N/S 4.1 %∗
Right hilar central Phase-gating 40–60 % phase 8.9 cm3 N/S 6.6 %∗
(n) CT
Non-active 4DCT ITV-based 14.0 cm3 N/S 7.9 %∗
Right upper Phase-gating 40–60 % phase 8.5 cm3 N/S 2.2 %∗
central (1) CT
Non-active 4DCT ITV-based 12.2 cm3 N/S 3.0 %∗
(continued on next page)
 Table 2 (continued)
B. Zhang, L. Marignol and M. Kearney / Journal of Medical Imaging and Radiation Sciences 56 (2025) 101860

Author, year No. of Diagnosis (no. Fractionation, Gy / Location of Respiratory Dataset used for Target Volume PTV Volumes Lung V5 Lung V20
Patients lesions) fraction, # tumours (no. Motion Delineation Definition
lesions) Management

Pokhrel et al., 12 Early-stage 54/3 Left (4) Non-active 3DCT+4DCT ITV=union of GTVs 38.7 ± 22.7 cm3 31.3 ± 11.4 % 6.6 ± 3.5 %
2019 NSCLC (12) 50/5 Right (2) MIP on 10 phases CT (mean ± SD) (mean ± SD) (mean ± SD)
Bilateral (6) PTV=ITV+5–10mm (15.9–91.8 cm3 ) (15.4–50.4 %) (2.9–13.5 %)
Nguyen et 13 Early-stage 55/5 Upper (1) DIBH DIBH CT For non-active ITV: 22.3 cm3 N/S N/S
al., 2023 NSCLC (13) Non-active 4DCT ITV-based ITV=union of GTVs 41.7 cm3 N/S N/S
52.5/7 Lower (1) DIBH DIBH CT on 10 phases CT 18.8 cm3 N/S N/S
Non-active 4DCT ITV-based PTV=ITV+5mm 55.9 cm3 N/S N/S
55/5 Lower (1) DIBH DIBH CT For DIBH: 21.7 cm3 N/S N/S
Non-active 4DCT ITV-based PTV=CTV+5mm 25.4 cm3 N/S N/S
55/5 Lower (1) DIBH DIBH CT 13.9 cm3 N/S N/S
Non-active 4DCT ITV-based 26.1 cm3 N/S N/S
55/5 Lower (1) DIBH DIBH CT 20.6 cm3 N/S N/S
50/5 Lower (1) DIBH DIBH CT 5.7 cm3 N/S N/S
Non-active 4DCT ITV-based 8.6 cm3 N/S N/S
50/5 Lower (1) DIBH DIBH CT 78.9 cm3 N/S N/S
60/8 Upper (1) DIBH DIBH CT 21.7 cm3 N/S N/S
60/8 Middle (1) DIBH DIBH CT 17.5 cm3 N/S N/S
Non-active 4DCT ITV-based 21.9 cm3 N/S N/S
50/5 Lower (1) DIBH DIBH CT 7.6 cm3 N/S N/S
Non-active 4DCT ITV-based 9.6 cm3 N/S N/S
55/5 Lower (1) DIBH DIBH CT 45.7 cm3 N/S N/S
Non-active 4DCT ITV-based 51.4 cm3 N/S N/S
55/5 Middle (1) DIBH DIBH CT 68.3 cm3 N/S N/S
Non-active 4DCT ITV-based 90.4 cm3 N/S N/S
55/5 Upper (1) DIBH DIBH CT 47.0 cm3 N/S N/S
Non-active 4DCT ITV-based 77.6 cm3 N/S N/S
(continued on next page)
9
10

Table 2 (continued)

Author, year No. of Diagnosis (no. Fractionation, Gy / Location of Respiratory Dataset used for Target Volume PTV Volumes Lung V5 Lung V20
Patients lesions) fraction, # tumours (no. Motion Delineation Definition
lesions) Management

Prunaretty et 10 Lung tumour (10) 60/4 Left upper (1) Non-active 4DCT ITV-based For non-active ITV: 2.66 cm3 N/S 3.58 %∗
al., 2019 Phase gating 40–60 % phase ITV=union of GTVs 1.8 cm3 N/S 2.72 %∗
CT on 10 phases CT
B. Zhang, L. Marignol and M. Kearney / Journal of Medical Imaging and Radiation Sciences 56 (2025) 101860

Tracking 4DCT PTV=ITV+3mm 1.38 cm3 N/S 1.95 %∗

Right lower (1) Non-active 4DCT ITV-based For phase gating: 4.41 cm3 N/S 3.15 %∗
Phase gating 40–60 % phase ITV=union of GTVs 2.58 cm3 N/S 1.54 %∗
CT on 40–60 % phase
Tracking 4DCT CT 2.57 cm3 N/S 1.96 %∗
Right lower (1) Non-active 4DCT ITV-based PTV=ITV+3mm 4.47 cm3 N/S 2.86 %∗
Phase gating 40–60 % % phase For tracking: 3.03 cm3 N/S 3.24 %∗
CT PTV=GTV on each
Tracking 4DCT phase+3mm 2.14 cm3 N/S 1.63 %∗
Right lower (1) Non-active 4DCT ITV-based 10 PTV created 7.83 cm3 N/S 8.67 %∗
Phase gating 40–60 % phase 5.11 cm3 N/S 7.09 %∗
CT
Tracking 4DCT 5.0 cm3 N/S 6.32 %∗
Right middle (1) Non-active 4DCT ITV-based 27.79 cm3 N/S 8.31 %∗
Phase gating 40–60 % phase 20.44 cm3 N/S 7.35 %∗
CT
Tracking 4DCT 17.3 cm3 N/S 5.63 %∗
Right lower (1) Non-active 4DCT ITV-based 27.61 cm3 N/S 8.97 %∗
Phase gating 40–60 % % phase 19.4 cm3 N/S 6.83 %∗
CT
Tracking 4DCT 17.19 cm3 N/S 6.35 %∗
Left lower (1) Non-active 4DCT ITV-based 9.14 cm3 N/S 4.82 %∗
Phase gating 40–60 % phase 4.96 cm3 N/S 4.10 %∗
CT
Tracking 4DCT 4.33 cm3 N/S 2.86 %∗
Right middle (1) Non-active 4DCT ITV-based 19.2 cm3 N/S 7.59 %∗
Phase gating 40–60 % phase 12.49 cm3 N/S 5.04 %∗
CT
Tracking 4DCT 9.91 cm3 N/S 4.21 %∗
Right lower (1) Non-active 4DCT ITV-based 13.12 cm3 N/S 8.79 %∗
Phase gating 40–60 % phase 6.61 cm3 N/S 6.18 %∗
CT
Tracking 4DCT 6.01 cm3 N/S 4.61 %∗
Left lower (1) Non-active 4DCT ITV-based 8.08 cm3 N/S 6.64 %∗
Phase gating 40–60 % phase 4.65 cm3 N/S 2.51 %∗
CT
Tracking 4DCT 2.64 cm3 N/S 2.66 %∗
∗ ipsilateral lung.
# patients have 2 lesions; N/S: not specified; NSCLC: non-small cell lung cancer; BH: breath-hold; DIBH: deep inspiration breath-hold; exp BH: expiration breath-hold; PTV: planning target volume; ITV:
internal target volume; CTV: clinical target volume; GTV: gross tumour volume; 4DCT: four-dimensional computed tomography; MLC: multi-leaf collimator; CT: computed tomography.
 Table 3
PTV volumes derived from included studies according to the respiratory motion management approach employed, the average and range of volume size was included.
PTV Volumes (cm3 )
Study∗ Average Range Average & Range
(a) Non-active
B. Zhang, L. Marignol and M. Kearney / Journal of Medical Imaging and Radiation Sciences 56 (2025) 101860

Holla et al. 72.87 Not specified

Morkeset et al. 32.28 3.28–78.90
Jaccard et al. 25.2 10.1–77.4
Lee et al. 23.5 4.0–99.5
Cheng et al. 40.1 14.7–112.5
Booth et al. 25.0 5.0–53.9
Saglam et al. 16.39 1.76–37.84
Kraus et al. 49.0 12.2–99.2
Pokhrel et al. 38.7 15.9–91.8
Nguyen et al., 40.9 8.6–90.4
2023
Prunaretty et al. 12.45 2.7–27.8
(b) Breath-hold
Holla et al. 46.5 Not specified
Morkeset et al. 23.46 9.06–61.52
Jaccard et al. 10.2 7.1–13.2
Lee et al. 23.2 4.2–57.8
Nguyen et al. 30.0 5.7–78.9
Li et al. Not specified 3.28–40
Miura et al. 32.6 18.3–57.4
(c) Gating
Cheng et al. 21.6 7.9–56.5
Kraus et al.+ 36.4 8.5–83.1
49.8 15.4–80.4
53.0 15.9–89.9
Prunaretty et al. 8.1 1.8–20.4
(d) Tracking
Holla et al. 33.75 Not specified
Booth et al. 18.6 3.9–39.6
Matsuo et al. 49.9 16–148
Prunaretty et al. 6.8 1.4–17.3

∗ Some studies reported PTV volumes from multiple respiratory motion management approaches used and so appeared more than once.
+ Kraus et al. reported 3 separate gated plans with different gating windows: 40–60 % GW, 20–40 % GW, and 20–70% GW.
11
Table 4
The mean and range of PTV volumes derived from all studies in each respiratory motion management approach.
Respiratory motion management Number of studies∗ PTV Volumes (cm3 )

Average Range
Non-active 11 36.35 1.76–112.50
Breath-hold 7 26.26 3.28–78.90
Gating 3 30.18 1.80–89.90
Tracking 4 12.48 1.40–148.0
∗ 10 studies reported PTV volumes from multiple respiratory motion management approaches and so contributed more than once.

ported absolute volume reduction with DIBH, reducing aver- patient group (Table 6). One study reported an 11.6 % (3.0–
age PTV volumes by 27.43 cm3 , 24.21 cm3 , 32.39 cm3 for 20.1 %) reduction in V5whole with phase-gating [38] Another
upper lobe, middle lobe and lower lobe, respectively. reported absolute reduction in V5whole with DIBH (2.8 %,
Three studies showed an average reduction of 32.9 % (8.1– 13.7 %, and 16.5 %) and tracking (4.8 %, 9.4 %, and 16.9 %)
66.0 %) in PTV volume between phase-gated and non-active [34] Jaccard et al. [36] showed a 27.4 % (14.7–42.4 %) average
technique in the same patient group. One study [38] found V5ipsi reduction with DIBH.
30–70 % phase-gated plans resulted in a 47.2 %. Two stud-
ies reported reduction of 26.5 % [30] and 37.0 % [31] with
40–60 % exhalation phase plans. Kraus et al. [30] reported V20 lung dose
greater reduction with a 40–60 % gating window (GW) (av- Eight studies [30,31,34-36,38,40,41] reported V20 for
erage 24.9 %) compared to 20–40 % (average 23.1 %) and non-active approach. with an average V20whole of 6.0 % (0.1–
20–70 % (average 15.0 %) windows. 13.5 %) in five studies [34,35,38,40,41]. The DIBH approach
Three studies compared the PTV volumes between track- reported an average V20whole of 4.6 % in one study [34] and
ing and non-active approaches in the same patient group, with another reporting 3.4 % (3.1–3.8 %) for V20ipsi [36]. Expira-
two studies [31,39] reporting an average reduction of 34.2 % tion BH reported an average V20whole of 4.1 % (2.5–5.5 %)
(36.1–67.3 %). One study [34] demonstrated a reduction of [44]. For phase-gating approach, one study [38] reported an
38.31 cm3 , 43.97 cm3 , 40.7 cm3 for upper lobe, middle lobe average V20whole of 3.1 % (1.6–6.0 %) for 30–70 % GW,
and lower lobe, respectively. and two studies [30,31] showing 6.6 % (1.5–16.7 %) for 40–
PTV volume reduction varied by tumour location. Lower 60 % GW. V20ipsi was reported in another study [30] show-
lobe tumours generally showed greater reduction compared ing 12.4 % (2.1–17.8 %) for 20–70 % GW, which is higher
to upper lobe tumours, although results varied. Two studies than 40–60 % GW (11.0 %, 2.0–16.7 %) and 20–40 % GW
[34,36] showed greater reduction in lower lobe tumours with (11.0 %, 1.9–16.6 %). Tracking approach studies reported an
DIBH (45 % vs. 30.1 % and 32.39 cm3 vs. 27.43 cm3 ), while average V20whole of 4.4 % [34] and an average V20ipsi of 3.8 %
another [42] showed greater reduction in upper lobe tumours (1.6–6.4 %) [31].
(32.3 % vs. 43.0 %). Phase-gating studies showed mixed re- V20 varied by tumour location, reported V20ipsi was higher
sults, with some reporting greater reduction in lower lobes in lower lobe (6.6 %) than in upper lobe (5.6 %) for non-
(39.4 % vs. 32.3 %) [31] and others in upper lobes (25.5 % active approach [30,31,36], same for DIBH (3.8 % vs. 3.3 %)
vs. 48.2 %) [30]. [36], phase-gating (5.7 % vs. 3.0 %) [30,31], and tracking
(3.8 % vs. 2.0 %) [31] approaches. Central lesions showed
Lung dosimetry higher V20ipsi than peripheral lesions for non-active (11.3 %
vs. 8.2 %) [30] and phase-gating (10.6 % vs. 6.8 %) [30] ap-
V5 lung dose proaches.
Four studies [34,38,40,41] reported V5whole for non-active
approach, with an average of 25.9 % (8.1–50.4 %). One study
[40] reported a median V5whole of 11.5 %. The DIBH tech- V20 lung dose reduction
nique showed an average V5whole of 20.9 % [34], while ex- Eight studies [30,31,34-39] (Table 6) compared V20 lung
piration BH showed 15.5 % (11.6–18.8 %) [44]. One study doses among different respiratory motion management ap-
[38] reported average V5whole of 14.1 % (8.5–19.7 %) for proaches. DIBH showed significant reduction, with one study
phase-gating, while another study [34] reported average V5whole reporting a 60 % reduction in V20whole [37] and another re-
for tracking (21.3 %). V5ipsi was reported in one study [36], porting 29.5 % (28.9–52.0 %) reduction in V20ipsi [36] in the
showing a reduction with DIBH. same patient group. Phase-gating showed an average reduction
of 31.1 % (19.6–48.8 %) in V20whole [38] and 20.2 % (-13.3–
V5 lung dose reduction 62.2 %) in V20ipsi [30,31]. Tracking showed an average reduc-
Three studies [34,36,38] reported reductions in V5 lung tion of 8.7 % in V20whole [39] and 39.3 % (27.1–47.6 %) in
dose between active and non-active approaches in the same V20ipsi [31].

12 B. Zhang, L. Marignol and M. Kearney / Journal of Medical Imaging and Radiation Sciences 56 (2025) 101860
 Table 5
B. Zhang, L. Marignol and M. Kearney / Journal of Medical Imaging and Radiation Sciences 56 (2025) 101860

Average and range of whole/ipsilateral lung V5 and V20 reported for the reviewed studies.
Lung doses (%)

No. of Average+ Range# Average & Range

studies∗
1. V5whole
Non-active 4 25.9 % 8.1–50.4 %
Breath-hold 3 15.0 % 11.6–18.8 %
Gating 1 14.1 % 8.5–19.7 %
Tracking 1 21.3 % Not specified
2. V5ipsi
Non-active 1 21.7 % 17.4–27.1 %
Breath-hold 1 15.6 % 11.8–18.7 %
3. V20whole
Non-active 5 6.0 % 0.1–13.5 %
Breath-hold 4 4.4 % 0.5–15.9 %
Gating 1 3.1 % 1.6–6.0 %
Tracking 2 4.4 % 1.0–10.7 %
4. V20ipsi
Non-active 3 8.3 % 2.2–22.9 %
Breath-hold 1 3.4 % 3.1–3.8 %
Gating 2 8.3 % 1.5–17.8 %
Tracking 1 3.8 % 1.6–6.4 %

∗ Some studies reported dose for both V5 and V20 and so contributed more than once.
+ Saglam et al. did not specify on the average lung dose; it is not included in the average reporting.
# Holla et al. did not specify on the range for lung doses; it is not included in the range reporting.
13
14
B. Zhang, L. Marignol and M. Kearney / Journal of Medical Imaging and Radiation Sciences 56 (2025) 101860

Table 6
Average and range of reduction in whole/ipsilateral lung V5 and V20 reported in the comparison studies.
Lung doses reduction (%)

No. of Average Range Average & Range

studies∗
5. V5whole
Gating 1 11.6 % 3.0–20.1 %
6. V5ipsi
DIBH 1 27.4 % 14.7–42.4 %
7. V20whole
DIBH 1 60 % Not specified
Gating 1 31.1 % 19.6–48.8 %
8. V20ipsi
DIBH 1 39.5 % 28.9–52 %
Gating 2 20.2 % -13.3–62.2 %
Tracking 1 39.2 % 27.1–47.6 %

∗ Some studies reported dose reduction for both V5 and V20 and so contributed more than once.
 Tables 5 and 6 summarises the average and range of inspiration BH studies. The BH approach reviewed primarily
whole/ipsilateral lung V5 and V20 reported and reduction re- focused on deep inspiration BH (DIBH).
ported across all studies. Compared to the non-active approach, Nguyen et al.
[42] demonstrated an average of 32.4 % (11.1–66.4 %) re-
duction in PTV volume using DIBH, while Jaccard et al.
Discussion
[36] showed that when DIBH is combined with electromag-
SBRT can be considered in inoperable early-stage primary netic transponders (EMT) tracking system, it resulted in a re-
lung cancer, lung metastases, and patients in lieu of surgery, rep- duction of PTV volume ranging from 29.4 % to 45 %, and
resenting about 20–30 % of this patient population [45]. Ef- 27.4 % (14.7–42.4 %) reduction in lung V5ipsi and a 39.5 %
fective respiratory motion management is essential to minimise (28.9–52.0 %) reduction in V20ipsi . These studies used volun-
target volumes and reduce lung toxicity without compromising tary DIBH, while Lee et al. [37] demonstrated an involuntary
treatment efficacy [46-48]. With various active and non-active DIBH approach using the active breathing control (ABC) sys-
motion management strategies extensively studied, this system- tem, showing a 19 % PTV volume reduction and a 60 % reduc-
atic review aims to define the magnitude of their impact on tion in lung V20whole . There is no significant difference between
volumetric and dosimetric outcomes [20,49,50], and highlight voluntary and involuntary DIBH approaches. Despite the re-
the challenges in selecting the most appropriate approach for duction in PTV volume due to reduced tumour motion, the
individual patients. Overall, we find that all active approaches dosimetric benefit of DIBH were also attributed to lung vol-
demonstrate superior volumetric and dosimetric benefits over ume expansion. Morketset et al. [35] reported a 42 % increase
non-active approaches. Specifically, tracking approach shows in lung volume with DIBH, resulting in a reduction of V20whole
superior target volume reductions (32.4 %) among all active ap- and mean lung dose (MLD). Three more studies [35-37] also
proaches while DIBH is superior in lung protection with com- reported lower lung doses when DIBH was used.
parable lung dose reduction to tracking approaches (39.5 % vs. In terms of tumour location, DIBH could be more benefi-
39.2 %), and superior dosimetric results over the phase-gating cial for patients with lower lobe tumours, as results from two
approach (39.5 % vs. 20.2 %). studies [34,36] indicated greater reductions in PTV volumes in
Radiation-induced pneumonitis (RP) remains a significant lower lobe tumours compared to upper lobe tumours. Tumour
side effect in lung SBRT, which varies widely in incidence and motion is greater in the lower lobe (median 7.7–9.2 mm) than
severity. Reports suggest that although most RP is grade 1 or in the upper lobe (median 1.7–3.3 mm) [60,61].
2 and either asymptomatic or manageable, severe and symp- However, BH approach comes with multiple challenges,
tomatic can be fatal. Overall incidence of symptomatic RP such as multiple long breath-holds are required to be formed
ranges from 9 % to 28 % [51], and there is an association be- during treatment, which is more difficult for lung cancer pa-
tween the irradiated volume and RP [52]. A consensus from tients due to insufficient respiratory capacity and poor per-
the HyTEC study [53] and ROSEL protocol [54] recommend formance status [62]. High patient compliance is required to
that lung dose-volume constraints for V20 be set at less than achieve shorter treatment time with longer breath-holds [59].
15 % for mandatory requirements and less than 10 % for op-
timal outcomes. Various respiratory motion management ap-
Gating
proaches have been implemented to reduce the impact of lung
doses. Lung dose reduction has translated into at least 2 % re- Unlike the BH technique, the phase-gated approach allows
ductions in normal tissue complication probability (NTCP) for patients to breathe freely during treatment, similar to the non-
radiation pneumonitis in lung radiotherapy [55,56]. active approach, enhancing patient comfort [63]. Treatment is
delivered during specific respiratory phases within the breath-
ing cycle, leading to significant volumetric and dosimetric ad-
Breath-hold
vantages over the non-active approach, as observed in three
Breath-hold (BH) was the most commonly reported active studies [30,31,38]. These studies reported an average reduction
respiratory motion management approach reviewed. This ap- of 32.9 % in PTV volume and average reduction of 11.6 % and
proach seeks to limit tumour motion and deliver radiation 31.1 %, in lung V5whole and V20whole , respectively. These bene-
specifically during a breath-hold (BH) [34]. When assessing the fits can be attributed to differences in target volume delineation,
benefit of the BH approach over a non-active approach, five as the ITV in phase-gating is restricted to the GTVs within a
studies [34-37,42] reported an average reduction in PTV vol- specific respiratory phase or gating window (GW), resulting in
ume of 23.9 %. A benefit in minimising artefacts from tumour smaller PTV volumes and reduced lung volumes being irradi-
motion and lesion location caused by the CT acquisition pro- ated [49].
cess was also identified, which could improve delineation accu- Greater reduction in PTV volumes were observed in lower
racy [17,35]. Inspiration BH was more common, possibly ow- lobe tumours compared to upper lobe tumours (39.4 % vs.
ing to the known challenge in achieving expiration BH [57-59]. 32.3 %) [31], as well as in peripheral tumours compared to cen-
Miura et al. [44], the only study reported on expiration BH, tral tumours (35.6 % vs. 22.9%) [30]. These differences can be
indicated comparable PTV volumes (32.6 cm3 vs. 30.0 cm3 ) explained by the greater motion exhibited by tumours located
[42] and V20whole lung doses (4.1 % vs. 4.6 %) [34] to those in in the lower lobe and peripheral regions [60,61,64]. The dosi-

B. Zhang, L. Marignol and M. Kearney / Journal of Medical Imaging and Radiation Sciences 56 (2025) 101860 15
metric benefits were also notable. Prunaretty et al. [31] reported to upper lobe tumours (1.2%). Prunaretty et al. [31] also high-
a greater reduction in lung V20ipsi for lower lobe tumours com- lighted better lung protection for tumours with motion of 1 cm
pared to upper lobe (26.7 % vs. 23.1 %). or more (44 %) compared to those with less motion (34 %). Ad-
All phase-gating studies were conducted at the exhalation ditionally, they reported a 15.8 % lower V20ipsi with tracking
phase [30,31,38], to take advantage of reduced residual tumour compared to phase-gating.
motion and a longer duty cycle than during inhalation, which Multiple systems have been developed for real-time tumour
improves reproducibility [25,63]. Phase-gating during maxi- monitoring, with fiducial markers being the most common
mum exhalation phase (40–60 %) resulted in an average reduc- [6,34]. Fiducial markers, detectable in x-ray or fluoroscopic im-
tion of 26.5–37 % in PTV volume and 19.9–25.6 % in lung ages, aid in precise tumour localisation, but concerns have been
V20ipsi [30,31]. The impact of different GWs on volumetric raised about imaging dose and potential skin exposure [72,73].
and dosimetric outcomes was highlighted by Kraus et al., who Booth et al. [39] described a non-radiographic method using
found that a 20–40 % GW produced comparable reductions magnetically tracked implantable transponders. However, fidu-
in PTV volumes (23.1 %) and lung V20ipsi (21.3 %) to the cial marker implantation may carry risks like pneumothorax,
40–60 % GW. with a high risk reported in patients with pulmonary lesions,
A trade-off between increased doses to organs at risk (OAR) and a marker migration rate of 19.0 % [74]. Challenges also
and shorter treatment time needs to be considered in the phase- arise in tracking the fiducial markers over multiple treatment
gating approach. While phase-gating treatment is associated sessions, as inaccuracies in the initial placement or shifting of
with longer treatment times due to smaller GW and lower the tumour relative to the fiducial during the respiratory cy-
duty cycle, it can lead to variations in respiratory pattern and cle can lead to errors in radiation delivery [75]. Robust and
intrafractional movement [25,65]. A larger GW allows for a consistent quality assurance procedures are required to ensure
higher duty cycle and shorter treatment times, but it might fiducial positioning stability, which necessitates additional ef-
compromise the volumetric and dosimetric benefits [66]. Pre- forts. Therefore, the use of fiducial marker tracking should be
vious studies have suggested that a GW of 30–70 % might be carefully evaluated for lung SBRT treatment.
the optimal GW for phase-gated treatment in order to achieve a
balance between treatment time and duty cycle [67,68]. Cheng
Limitations
et al.’s finding of largest lung dose reduction of 31.1 % further
proves that 30–70 % GW is more ideal [38]. This review has several limitations. Few studies directly com-
pare active and non-active approaches within the same patient
cohort, complicating cross-study comparisons. Bias may exist
Tracking
due to institutional preferences for certain approaches or po-
Similar to the non-active and phase-gating approach, the tential conflicts of interest. Additionally, variability in the re-
tracking approach allows patients to breathe freely during porting of lung dosimetric parameters hindered a comprehen-
treatment. Tumour tracking is achieved through robotic ra- sive data evaluation. Although established protocols define lung
diosurgery or dynamic multi-leaf collimators (DMLC), com- dose-volume parameters based on the whole lung excluding the
bined with an imaging system for real-time tumour track- target, the reviewed studies varied in the dosimetric parameters
ing [69]. Three of the four studies reviewed reported smaller reported, making meaningful comparisons of lung dosimetry
PTV volumes with tracking compared to non-active methods across studies challenging.
[31,34,39], with an average PTV reduction of 34.2 %, the Moreover, all the reviewed studies included relatively small
highest among active approaches. Another study by Matsuo patient cohorts, with the largest consisting of 48 patients. While
et al. [6] reported larger PTV volumes due to the larger lung tu- patient characteristics were generally similar across studies, not
mours and greater motion in their patient cohort, though they all studies detailed tumour motion and tumour volumes for
referenced another study suggesting that tracking could reduce each patient, typically providing only PTV. Additionally, co-
PTV volumes more than the mid-ventilation approach [70]. morbidities were not controlled for, with some patients having
The volumetric benefits of the tracking approach are derived concurrent diseases and lung issues that could influenced the
from real-time monitoring of tumour motion, which dynami- results, particularly with respect to tumour motion.
cally repositions the radiation beam, potentially eliminating the Currently, there are limited randomised controlled trials and
need for motion margins [20,71]. This capability was evident established guidelines for respiratory motion management in
in two studies where the PTV margin was directly added to the lung SBRT. Whilst the present review does not offer a definitive
GTV [31,39]. Holla et al. [34] used smaller PTV margins in the solution for mitigating the volumetric and dosimetric impacts
tracking approach compared to the non-active and DIBH ap- of each approach described in the literature, it does highlight
proach (3 mm vs. 5 mm), attributing the smaller margins to the the inconsistencies in data collection and reporting. These in-
orthogonal imaging system localisation. Tighter margins result consistencies make it difficult to draw firm conclusion about
in less irradiated lung volume, with a 39.2 % reduction in lung the relative benefits or drawbacks of each technique and em-
dose using the tracking approach, especially for tumours with phasise the need for well-designed, controlled studies to better
greater motion. Holla et al. [34] reported a greater absolute re- assess clinical outcomes. Compounding these challenges is the
duction of V20whole in lower lobe tumours (2.9 %) compared significant heterogeneity of patient populations, with ages rang-

16 B. Zhang, L. Marignol and M. Kearney / Journal of Medical Imaging and Radiation Sciences 56 (2025) 101860
ing from 22 to 94 years and multiple co-morbidities that have [3] Murray P, Franks K, Hanna GG. A systematic review of outcomes fol-
not been thoroughly address in many studies which may not lowing stereotactic ablative radiotherapy in the treatment of early-stage
primary lung cancer. Br J Radiol. 2017;90(1071):20160732.
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