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Elshof J, Steenstra C, Niezink A, Wijkstra P, Wijsman R, Duiverman M. Continuous and bilevel positive airway pressure may improve radiotherapy delivery in patients with intra-thoracic tumors. Clin Transl Radiat Oncol 2024; 47:100784. [PMID: 38706725 PMCID: PMC11063599 DOI: 10.1016/j.ctro.2024.100784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 04/11/2024] [Accepted: 04/20/2024] [Indexed: 05/07/2024] Open
Abstract
Background Minimizing tumor motion in radiotherapy for intra-thoracic tumors reduces side-effects by limiting radiation exposure to healthy tissue. Continuous or Bilevel Positive Airway Pressure (CPAP/BiPAP) could achieve this, since it could increase lung inflation and decrease tidal volume variability. We aim to identify the better CPAP/BiPAP setting for minimizing tumor motion. Methods In 10 patients (5 with lung cancer, 5 with other intra-thoracic tumors), CPAP/BiPAP was tested with the following settings for 10 min each: CPAP 5, 10 and 15 cmH2O and BiPAP 14/10 cmH2O with a lower (7 breaths/min) and higher back-up respiratory rate (BURR initially 1 breath/min above the spontaneous breathing frequency, with the option to adjust if the patient continued to initiate breaths). Electrical impedance tomography was used to analyse end-expiratory lung impedance (EELI) as an estimate of end-expiratory lung volume and tidal impedance variation (TIV) as an estimate of tidal volume. Results Nine out of ten patients tolerated all settings; one patient could not sustain CPAP-15. A significant difference in EELI was observed between settings (χ2 22.960, p < 0.001), with most increase during CPAP-15 (median (IQR) 1.03 (1.00 - 1.06), normalized to the EELI during spontaneous breathing). No significant differences in TIV and breathing variability were found between settings. Conclusions This study shows that the application of different settings of CPAP/BiPAP in patients with intra-thoracic tumors is feasible and tolerable. BiPAP with a higher BURR may offer the greatest potential for mitigating tumor motion among the applied settings, although further research investigating tumor motion should be conducted.
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Affiliation(s)
- J. Elshof
- Department of Pulmonary Diseases/Home Mechanical Ventilation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Groningen Research Institute for Asthma and COPD, University of Groningen, Groningen, The Netherlands
| | - C.M. Steenstra
- Department of Pulmonary Diseases/Home Mechanical Ventilation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Groningen Research Institute for Asthma and COPD, University of Groningen, Groningen, The Netherlands
| | - A.G.H. Niezink
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - P.J. Wijkstra
- Department of Pulmonary Diseases/Home Mechanical Ventilation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Groningen Research Institute for Asthma and COPD, University of Groningen, Groningen, The Netherlands
| | - R. Wijsman
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - M.L. Duiverman
- Department of Pulmonary Diseases/Home Mechanical Ventilation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Groningen Research Institute for Asthma and COPD, University of Groningen, Groningen, The Netherlands
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Loÿen E, Dasnoy-Sumell D, Macq B. Patient-specific three-dimensional image reconstruction from a single X-ray projection using a convolutional neural network for on-line radiotherapy applications. Phys Imaging Radiat Oncol 2023; 26:100444. [PMID: 37197152 PMCID: PMC10183662 DOI: 10.1016/j.phro.2023.100444] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 04/06/2023] [Accepted: 04/25/2023] [Indexed: 05/19/2023] Open
Abstract
Background and purpose: Radiotherapy is commonly chosen to treat thoracic and abdominal cancers. However, irradiating mobile tumors accurately is extremely complex due to the organs' breathing-related movements. Different methods have been studied and developed to treat mobile tumors properly. The combination of X-ray projection acquisition and implanted markers is used to locate the tumor in two dimensions (2D) but does not provide three-dimensional (3D) information. The aim of this work is to reconstruct a high-quality 3D computed tomography (3D-CT) image based on a single X-ray projection to locate the tumor in 3D without the need for implanted markers. Materials and Methods: Nine patients treated for a lung or liver cancer in radiotherapy were studied. For each patient, a data augmentation tool was used to create 500 new 3D-CT images from the planning four-dimensional computed tomography (4D-CT). For each 3D-CT, the corresponding digitally reconstructed radiograph was generated, and the 500 2D images were input into a convolutional neural network that then learned to reconstruct the 3D-CT. The dice score coefficient, normalized root mean squared error and difference between the ground-truth and the predicted 3D-CT images were computed and used as metrics. Results: Metrics' averages across all patients were 85.5% and 96.2% for the gross target volume, 0.04 and 0.45 Hounsfield unit (HU), respectively. Conclusions: The proposed method allows reconstruction of a 3D-CT image from a single digitally reconstructed radiograph that could be used in real-time for better tumor localization and improved treatment of mobile tumors without the need for implanted markers.
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Vander Veken L, Van Ooteghem G, Razavi A, Da Rita Quaresma S, Longton E, Kirkove C, Ledoux B, Vandermeulen A, Abdel Massih C, Henderickx P, Gabriels M, Delvaux C, Salah F, Vaandering A, Geets X. Voluntary versus mechanically-induced deep inspiration breath-hold for left breast cancer: A randomized controlled trial. Radiother Oncol 2023; 183:109598. [PMID: 36898583 DOI: 10.1016/j.radonc.2023.109598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 02/14/2023] [Accepted: 02/28/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND AND PURPOSE Deep inspiration breath-hold (DIBH) protects critical organs-at-risk (OARs) for adjuvant breast radiotherapy. Guidance systems e.g. surface guided radiation therapy (SGRT) improve the positional breast reproducibility and stability during DIBH. In parallel, OARs sparing with DIBH is enhanced through different techniques e.g. prone position, continuous positive airway pressure (CPAP). By inducing repeated DIBH with the same level of positive pressure, mechanically-assisted and non-invasive ventilation (MANIV) could potentially combine these DIBH optimizations. MATERIALS AND METHODS We conducted a randomized, open-label, multicenter and single-institution non-inferiority trial. Sixty-six patients eligible for adjuvant left whole-breast radiotherapy in supine position were equally assigned between mechanically-induced DIBH (MANIV-DIBH) and voluntary DIBH guided by SGRT (sDIBH). The co-primary endpoints were positional breast stability and reproducibility with a non-inferiority margin of 1 mm. Secondary endpoints were tolerance assessed daily via validated scales, treatment time, dose to OARs and their inter-fraction positional reproducibility. RESULTS Differences between both arms for positional breast reproducibility and stability occurred at a sub-millimetric level (p < 0.001 for non-inferiority). The left anterior descending artery near-max dose (14,6 ± 12,0 Gy vs. 7,7 ± 7,1 Gy, p = 0,018) and mean dose (5,0 ± 3,5 Gy vs. 3,0 ± 2,0 Gy, p = 0,009) were improved with MANIV-DIBH. The same applied for the V5Gy of the left ventricle (2,4 ± 4,1 % vs. 0,8 ± 1,6 %, p = 0,001) as well as for the left lung V20Gy (11,4 ± 2,8 % vs. 9,7 ± 2,7 %, p = 0,019) and V30Gy (8,0 ± 2,6 % vs. 6,5 ± 2,3 %, p = 0,0018). Better heart's inter-fraction positional reproducibility was observed with MANIV-DIBH. Tolerance and treatment time were similar. CONCLUSION Mechanical ventilation provides the same target irradiation accuracy as with SGRT while better protecting and repositioning OARs.
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Affiliation(s)
- Loïc Vander Veken
- UCLouvain, Institut de Recherche Experimentale et Clinique (IREC), Center of Molecular Imaging, Radiotherapy and Oncology (MIRO), 1200 Brussels, Belgium; Radiation Oncology Department, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium.
| | - Geneviève Van Ooteghem
- UCLouvain, Institut de Recherche Experimentale et Clinique (IREC), Center of Molecular Imaging, Radiotherapy and Oncology (MIRO), 1200 Brussels, Belgium; Radiation Oncology Department, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Ariane Razavi
- Radiation Oncology Department, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | | | - Eleonore Longton
- Radiation Oncology Department, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Carine Kirkove
- Radiation Oncology Department, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Benjamin Ledoux
- Radiation Oncology Department, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Ad Vandermeulen
- Radiation Oncology Department, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Christel Abdel Massih
- Radiation Oncology Department, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Pascale Henderickx
- Radiation Oncology Department, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Mortimer Gabriels
- Radiation Oncology Department, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Céline Delvaux
- Radiation Oncology Department, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Faycal Salah
- Radiation Oncology Department, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Aude Vaandering
- UCLouvain, Institut de Recherche Experimentale et Clinique (IREC), Center of Molecular Imaging, Radiotherapy and Oncology (MIRO), 1200 Brussels, Belgium; Radiation Oncology Department, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Xavier Geets
- UCLouvain, Institut de Recherche Experimentale et Clinique (IREC), Center of Molecular Imaging, Radiotherapy and Oncology (MIRO), 1200 Brussels, Belgium; Radiation Oncology Department, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
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van Kesteren Z, Veldman JK, Parkes MJ, Stevens MF, Balasupramaniam P, van den Aardweg JG, van Tienhoven G, Bel A, van Dijk IWEM. Quantifying the reduction of respiratory motion by mechanical ventilation with MRI for radiotherapy. Radiat Oncol 2022; 17:99. [PMID: 35597956 PMCID: PMC9123684 DOI: 10.1186/s13014-022-02068-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 05/12/2022] [Indexed: 12/13/2022] Open
Abstract
Background Due to respiratory motion, accurate radiotherapy delivery to thoracic and abdominal tumors is challenging. We aimed to quantify the ability of mechanical ventilation to reduce respiratory motion, by measuring diaphragm motion magnitudes in the same volunteers during free breathing (FB), mechanically regularized breathing (RB) at 22 breaths per minute (brpm), variation in mean diaphragm position across multiple deep inspiration breath-holds (DIBH) and diaphragm drift during single prolonged breath-holds (PBH) in two MRI sessions. Methods In two sessions, MRIs were acquired from fifteen healthy volunteers who were trained to be mechanically ventilated non-invasively We measured diaphragm motion amplitudes during FB and RB, the inter-quartile range (IQR) of the variation in average diaphragm position from one measurement over five consecutive DIBHs, and diaphragm cranial drift velocities during single PBHs from inhalation (PIBH) and exhalation (PEBH) breath-holds. Results RB significantly reduced the respiratory motion amplitude by 39%, from median (range) 20.9 (10.6–41.9) mm during FB to 12.8 (6.2–23.8) mm. The median IQR for variation in average diaphragm position over multiple DIBHs was 4.2 (1.0–23.6) mm. During single PIBHs with a median duration of 7.1 (2.0–11.1) minutes, the median diaphragm cranial drift velocity was 3.0 (0.4–6.5) mm/minute. For PEBH, the median duration was 5.8 (1.8–10.2) minutes with 4.4 (1.8–15.1) mm/minute diaphragm drift velocity. Conclusions Regularized breathing at a frequency of 22 brpm resulted in significantly smaller diaphragm motion amplitudes compared to free breathing. This would enable smaller treatment volumes in radiotherapy. Furthermore, prolonged breath-holding from inhalation and exhalation with median durations of six to seven minutes are feasible. Trial registration Medical Ethics Committee protocol NL.64693.018.18.
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Affiliation(s)
- Z van Kesteren
- Department of Radiation Oncology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
| | - J K Veldman
- Department of Radiation Oncology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - M J Parkes
- Department of Radiation Oncology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - M F Stevens
- Department of Anesthesiology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.,Department of Anesthesiology, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
| | - P Balasupramaniam
- Department of Radiation Oncology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - J G van den Aardweg
- Department of Pulmonology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - G van Tienhoven
- Department of Radiation Oncology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - A Bel
- Department of Radiation Oncology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - I W E M van Dijk
- Department of Radiation Oncology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
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Vander Veken L, Dechambre D, Sterpin E, Souris K, Van Ooteghem G, Aldo Lee J, Geets X. Incorporation of tumor motion directionality in margin recipe: The directional MidP strategy. Phys Med 2021; 91:43-53. [PMID: 34710790 DOI: 10.1016/j.ejmp.2021.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 08/03/2021] [Accepted: 10/09/2021] [Indexed: 12/24/2022] Open
Abstract
PURPOSE Planning target volume (PTV) definition based on Mid-Position (Mid-P) strategy typically integrates breathing motion from tumor positions variances along the conventional axes of the DICOM coordinate system. Tumor motion directionality is thus neglected even though it is one of its stable characteristics in time. We therefore propose the directional MidP approach (MidP dir), which allows motion directionality to be incorporated into PTV margins. A second objective consists in assessing the ability of the proposed method to better take care of respiratory motion uncertainty. METHODS 11 lung tumors from 10 patients with supra-centimetric motion were included. PTV were generated according to the MidP and MidP dir strategies starting from planning 4D CT. RESULTS PTVMidP dir volume didn't differ from the PTVMidP volume: 31351 mm3 IC95% [17242-45459] vs. 31003 mm3 IC95% [ 17347-44659], p = 0.477 respectively. PTVMidP dir morphology was different and appeared more oblong along the main motion axis. The relative difference between 3D and 4D doses was on average 1.09%, p = 0.011 and 0.74%, p = 0.032 improved with directional MidP for D99% and D95%. D2% was not significantly different between both approaches. The improvement in dosimetric coverage fluctuated substantially from one lesion to another and was all the more important as motion showed a large amplitude, some obliquity with respect to conventional axes and small hysteresis. CONCLUSIONS Directional MidP method allows tumor motion to be taken into account more tightly as a geometrical uncertainty without increasing the irradiation volume.
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Affiliation(s)
- Loïc Vander Veken
- UCLouvain, Institut de Recherche Experimentale et Clinique (IREC), Center of Molecular Imaging, Radiotherapy and Oncology(MIRO), 1200 Brussels, Belgium.
| | - David Dechambre
- Radiation Oncology Department, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Edmond Sterpin
- UCLouvain, Institut de Recherche Experimentale et Clinique (IREC), Center of Molecular Imaging, Radiotherapy and Oncology(MIRO), 1200 Brussels, Belgium; KULeuven Department of Oncology, Laboratory of Experimental Radiotherapy, 3000 Leuven, Belgium
| | - Kevin Souris
- UCLouvain, Institut de Recherche Experimentale et Clinique (IREC), Center of Molecular Imaging, Radiotherapy and Oncology(MIRO), 1200 Brussels, Belgium
| | - Geneviève Van Ooteghem
- UCLouvain, Institut de Recherche Experimentale et Clinique (IREC), Center of Molecular Imaging, Radiotherapy and Oncology(MIRO), 1200 Brussels, Belgium; Radiation Oncology Department, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - John Aldo Lee
- UCLouvain, Institut de Recherche Experimentale et Clinique (IREC), Center of Molecular Imaging, Radiotherapy and Oncology(MIRO), 1200 Brussels, Belgium
| | - Xavier Geets
- UCLouvain, Institut de Recherche Experimentale et Clinique (IREC), Center of Molecular Imaging, Radiotherapy and Oncology(MIRO), 1200 Brussels, Belgium; Radiation Oncology Department, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
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Vakaet V, Van Hulle H, Schoepen M, Van Caelenberg E, Van Greveling A, Holvoet J, Monten C, De Baerdemaeker L, De Neve W, Coppens M, Veldeman L. Prolonging deep inspiration breath-hold time to 3 min during radiotherapy, a simple solution. Clin Transl Radiat Oncol 2021; 28:10-16. [PMID: 33732910 PMCID: PMC7941008 DOI: 10.1016/j.ctro.2021.02.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 02/17/2021] [Accepted: 02/17/2021] [Indexed: 01/07/2023] Open
Abstract
A new protocol was developped to prolong deep inspiration breath-holds. Multiple prolonged breath-holds are achievable with minimal side effects. DIBH was prolonged to 3 min using HFNO and hyperventilation in breast cancer patients.
Background and purpose Deep inspiration breath-hold is an established technique to reduce heart dose during breast cancer radiotherapy. However, modern breast cancer radiotherapy techniques with lymph node irradiation often require long beam-on times of up to 5 min. Therefore, the combination with deep inspiration breath-hold (DIBH) becomes challenging. A simple support technique for longer duration deep inspiration breath-hold (L-DIBH), feasible for daily use at the radiotherapy department, is required to maximize heart sparing. Materials and methods At our department, a new protocol for multiple L-DIBH of at least 2 min and 30 s was developed on 32 healthy volunteers and validated on 8 breast cancer patients during radiotherapy treatment, using a pragmatic process of iterative development, including all major stakeholders. Each participant performed 12 L-DIBHs, on 4 different days. Different methods of pre-oxygenation and voluntary hyperventilation were tested, and scored on L-DIBH duration, ease of use, and comfort. Results Based on 384 L-DIBHs from 32 healthy volunteers, voluntary hyperventilation for 3 min whilst receiving high-flow nasal oxygen at 40 L/min was the most promising technique. During validation, the median L-DIBH duration in prone position of 8 breast cancer patients improved from 59 s without support to 3 min and 9 s using the technique (p < 0.001). Conclusion A new and simple L-DIBH protocol was developed feasible for daily use at the radiotherapy center.
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Affiliation(s)
- Vincent Vakaet
- Department of Human Structure and Repair, Ghent University, Belgium.,Department of Radiation Oncology, Ghent University Hospital, Belgium
| | - Hans Van Hulle
- Department of Human Structure and Repair, Ghent University, Belgium
| | - Max Schoepen
- Department of Human Structure and Repair, Ghent University, Belgium.,Department of Industrial Systems Engineering and Product Design, Kortrijk, Belgium
| | | | | | - Jeroen Holvoet
- Department of Radiation Oncology, Ghent University Hospital, Belgium
| | - Chris Monten
- Department of Human Structure and Repair, Ghent University, Belgium.,Department of Radiation Oncology, Ghent University Hospital, Belgium
| | - Luc De Baerdemaeker
- Department of Anesthesia, Ghent University Hospital, Belgium.,Department of Basic and Applied Medical Sciences, Ghent University, Belgium
| | - Wilfried De Neve
- Department of Human Structure and Repair, Ghent University, Belgium.,Department of Radiation Oncology, Ghent University Hospital, Belgium
| | - Marc Coppens
- Department of Anesthesia, Ghent University Hospital, Belgium.,Department of Basic and Applied Medical Sciences, Ghent University, Belgium
| | - Liv Veldeman
- Department of Human Structure and Repair, Ghent University, Belgium.,Department of Radiation Oncology, Ghent University Hospital, Belgium
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