An Evaluation of Total Internal Motions of Locally Advanced Pancreatic Cancer during SABR Using Calypso Extracranial Tracking, and Its Possible Clinical Impact on Motion Management.

(1) Background: the aims of this study were to determine the total extent of pancreatic cancer's internal motions, using Calypso extracranial tracking, and to indicate possible clinical advantages of continuous intrafractional fiducial-based tumor motion tracking during SABR. (2) Methods: thirty-four patients were treated with SABR for LAPC using Calypso for motion management. Planning MSCTs in FB and DBH, and 4D-CTs were performed. Using data from Calypso and 4D-CTs, the movements of the lesions in the CC, AP and LR directions, as well as the volumes of the 4D-CT-based ITV and the volumes of the Calypso-based ITV were compared. (3) Results: significantly larger medians of tumor excursions were found with Calypso than with 4D-CT: CC: 29 mm ( < 0.001); AP: 14 mm ( < 0.001) and LR: 11 mm ( < 0.039). The median volume of the Calypso-based ITV was significantly larger than that of the 4D-CT based ITV ( < 0.001). (4) Conclusion: beside known respiratory-induced internal motions, pancreatic cancer seems to have significant additional motions which should be considered during respiratory motion management. Only direct and continuous intrafractional fiducial-based motion tracking seems to provide complete coverage of the target lesion with the prescribed isodose, which could allow for safe tumor dose escalation.