Application of 4DCT-Based Pulmonary Ventilation Imaging in Lung Cancer Radiotherapy

This study retrospectively evaluates a functional lung-guided radiotherapy planning workflow based on four-dimensional CT (4DCT) ventilation imaging in patients with primary lung cancer who previously underwent thoracic radiotherapy.

High-quality 4DCT datasets acquired during routine simulation are processed to generate voxel-based lung ventilation maps using deformable image registration and Jacobian-based computational methods. These ventilation maps are spatially registered to planning CT images and incorporated into the treatment planning system to delineate high-function lung subregions.

For each eligible patient, paired radiotherapy plans are retrospectively generated and analyzed: a conventional anatomic radiotherapy plan and a functional lung avoidance radiotherapy (FLAR) plan that incorporates ventilation-defined avoidance structures. Both plans are optimized to achieve comparable target coverage while differing in lung avoidance strategy.

Dosimetric and clinical data are obtained from existing treatment planning records and routine clinical follow-up to support comparative analyses of functional lung sparing and associated pulmonary outcomes. All analyses are conducted retrospectively using data derived from standard clinical care. No prospective enrollment, additional imaging, or study-specific interventions are performed.

Inclusion criteria

• Histologically confirmed primary lung cancer (adenocarcinoma, squamous cell carcinoma, or small-cell carcinoma) treated with thoracic radiotherapy.
• High-quality 4DCT scans performed before radiotherapy, enabling generation of ventilation or perfusion maps.
• Radiotherapy plans designed using IMRT.
• Availability of both functional lung avoidance plans and conventional anatomical radiotherapy plans for paired analysis.
• Complete treatment and follow-up records, including radiation-induced lung injury (e.g., radiation pneumonitis) and pulmonary function tests.

Exclusion criteria

• Incomplete or poor-quality imaging data preventing accurate ventilation/perfusion map generation.
• Radiotherapy interrupted or incomplete for any reason.
• Severe underlying lung diseases (e.g., extensive emphysema, pulmonary fibrosis, active tuberculosis) that may confound treatment outcomes or toxicity assessment.
• Presence of other untreated primary malignancies during the study period.
• Prior lung surgery or local therapies (e.g., ablation) that may affect evaluation of radiation-induced lung injury.
• Missing follow-up data, making assessment of radiation-induced lung injury or long-term lung function changes impossible.