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Cheng JC, Buduhan G, Venkataraman S, Tan L, Sasaki D, Bashir B, Ahmed N, Kidane B, Sivananthan G, Koul R, Leylek A, Butler J, McCurdy B, Wong R, Kim JO. Endobronchially Implanted Real-Time Electromagnetic Transponder Beacon-Guided, Respiratory-Gated SABR for Moving Lung Tumors: A Prospective Phase 1/2 Cohort Study. Adv Radiat Oncol 2023; 8:101243. [PMID: 37408673 PMCID: PMC10318214 DOI: 10.1016/j.adro.2023.101243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 04/03/2023] [Indexed: 07/07/2023] Open
Abstract
Purpose Endobronchial electromagnetic transponder beacons (EMT) provide real-time, precise positional data of moving lung tumors. We report results of a phase 1/2, prospective, single-arm cohort study evaluating the treatment planning effects of EMT-guided SABR for moving lung tumors. Methods and Materials Eligible patients were adults, Eastern Cooperative Oncology Group 0 to 2, with T1-T2N0 non-small cell lung cancer or pulmonary metastasis ≤4 cm with motion amplitude ≥5 mm. Three EMTs were endobronchially implanted using navigational bronchoscopy. Four-dimensional free-breathing computed tomography simulation scans were obtained, and end-exhalation phases were used to define the gating window internal target volume. A 3-mm expansion of gating window internal target volume defined the planning target volume (PTV). EMT-guided, respiratory-gated (RG) SABR was delivered (54 Gy/3 fractions or 48 Gy/4 fractions) using volumetric modulated arc therapy. For each RG-SABR plan, a 10-phase image-guided SABR plan was generated for dosimetric comparison. PTV/organ-at-risk (OAR) metrics were tabulated and analyzed using the Wilcoxon signed-rank pair test. Treatment outcomes were evaluated using RECIST (Response Evaluation Criteria in Solid Tumours; version 1.1). Results Of 41 patients screened, 17 were enrolled and 2 withdrew from the study. Median age was 73 years, with 7 women. Sixty percent had T1/T2 non-small cell lung cancer and 40% had M1 disease. Median tumor diameter was 1.9 cm with 73% of targets located peripherally. Mean respiratory tumor motion was 1.25 cm (range, 0.53-4.04 cm). Thirteen tumors were treated with EMT-guided SABR and 47% of patients received 48 Gy in 4 fractions while 53% received 54 Gy in 3 fractions. RG-SABR yielded an average PTV reduction of 46.9% (P < .005). Lung V5, V10, V20, and mean lung dose had mean relative reductions of 11.3%, 20.3%, 31.1%, and 20.3%, respectively (P < .005). Dose to OARs was significantly reduced (P < .05) except for spinal cord. At 6 months, mean radiographic tumor volume reduction was 53.5% (P < .005). Conclusions EMT-guided RG-SABR significantly reduced PTVs of moving lung tumors compared with image-guided SABR. EMT-guided RG-SABR should be considered for tumors with large respiratory motion amplitudes or those located in close proximity to OARs.
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Affiliation(s)
- Jui Chih Cheng
- Radiation Oncology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Gordon Buduhan
- Thoracic Surgery, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Lawrence Tan
- Thoracic Surgery, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - David Sasaki
- Medical Physics, CancerCare Manitoba, Winnipeg, Manitoba, Canada
| | - Bashir Bashir
- Radiation Oncology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Naseer Ahmed
- Radiation Oncology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Biniam Kidane
- Thoracic Surgery, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Gokulan Sivananthan
- Radiation Oncology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rashmi Koul
- Radiation Oncology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ahmet Leylek
- Radiation Oncology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - James Butler
- Radiation Oncology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Boyd McCurdy
- Medical Physics, CancerCare Manitoba, Winnipeg, Manitoba, Canada
| | - Ralph Wong
- Medical Oncology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Julian O. Kim
- Radiation Oncology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- CancerCare Manitoba Research Institute, Winnipeg, Manitoba, Canada
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Ku KM, Lam B, Wu VWC, Chan KT, Chan CYY, Cheng HC, Yuen KMY, Cai J. Clinical Evaluation of Fiducial Marker Pre-Planning for Virtual Bronchoscopic Navigation Implantation in Lung Tumour Patients Treated With CyberKnife. Front Oncol 2022; 12:860641. [PMID: 35785178 PMCID: PMC9246503 DOI: 10.3389/fonc.2022.860641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 05/13/2022] [Indexed: 11/20/2022] Open
Abstract
Purpose For the treatment of invisible lung tumours with CyberKnife (CK), fiducial markers (FMs) were implanted as an internal surrogate under virtual bronchoscopic navigation (VBN). This research aims to study the benefits of introducing an additional procedure in assigning the optimal FM positions using a pre-procedure planning system and performing virtual simulation before implantation. The objectives were 1) to reduce the duration of the FM implantation procedure, 2) to reduce the radiation exposure in dose area product (DAP) (dGy*cm2) to patients, and 3) to increase the number of FMs implanted around the tumour. Methods and Materials This study is retrospective, single-centre, and observational in nature. A total of 32 patients were divided into two groups. In Group 1, 18 patients underwent conventional VBN FM implantation. In Group 2, 14 patients underwent additional pre-procedure planning and simulation. The steps of pre-procedure planning include 1) importing CT images into the treatment planning system (Eclipse, Varian Medical Systems, Inc.) and delineating five to six FMs in their ideal virtual positions and 2) copying the FM configuration into VBN planning software (LungPoint Bronchus Medical, Inc.) for verification and simulation. Finally, the verified FMs were deployed through VBN with the guidance of the LungPoint planning software. Results A total of 162 FMs were implanted among 35 lesions in 32 patients aged from 37 to 92 (median = 66; 16 men and 16 women). Results showed that 1) the average FM insertion time was shortened from 41 min (SD = 2.05) to 23 min (SD = 1.25), p = 0.00; 2) the average absorbed dose of patients in DAP was decreased from 67.4 cGy*cm2 (SD = 14.48) to 25.3 cGy*cm2 (SD = 3.82), p = 0.01 (1-tailed); and 3) the average number of FMs implanted around the tumour was increased from 4.7 (SD = 0.84) to 5.6 (SD = 0.76), p = 0.00 (1-tailed). Conclusion Pre-procedure planning reduces the FM implantation duration from 41.1 to 22.9 min, reduces the radiation exposure in DAP from 67.4 to 25.3 dGy*cm2, and increases the number of FMs inserted around the tumour from 4.7 to 5.6.
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Affiliation(s)
- Ki Man Ku
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong, Hong Kong SAR, China
- Hong Kong Radiation Therapy Company Limited, Hong Kong, Hong Kong SAR, China
| | - Bing Lam
- Respiratory Medicine Centre, Hong Kong Sanatorium and Hospital, Hong Kong, Hong Kong SAR, China
| | - Vincent W. C. Wu
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong, Hong Kong SAR, China
| | - Kwok Ting Chan
- Department of Radiotherapy, Hong Kong Sanatorium and Hospital, Hong Kong, Hong Kong SAR, China
| | - Chloe Y. Y. Chan
- Department of Radiotherapy, Hong Kong Sanatorium and Hospital, Hong Kong, Hong Kong SAR, China
| | - H. C. Cheng
- Hong Kong Medical Physics Consulting Company Limited, Hong Kong, Hong Kong SAR, China
| | - Kamy M. Y. Yuen
- Hong Kong Radiation Therapy Company Limited, Hong Kong, Hong Kong SAR, China
| | - Jing Cai
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong, Hong Kong SAR, China
- Research Institute for Smart Aging, The Hong Kong Polytechnic University, Hong Kong, Hong Kong SAR, China
- *Correspondence: Jing Cai,
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Precisely translating computed tomography diagnosis accuracy into therapeutic intervention by a carbon-iodine conjugated polymer. Nat Commun 2022; 13:2625. [PMID: 35551194 PMCID: PMC9098856 DOI: 10.1038/s41467-022-30263-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 04/23/2022] [Indexed: 12/24/2022] Open
Abstract
X-ray computed tomography (CT) has an important role in precision medicine. However, CT contrast agents with high efficiency and the ability to translate diagnostic accuracy into therapeutic intervention are scarce. Here, poly(diiododiacetylene) (PIDA), a conjugated polymer composed of only carbon and iodine atoms, is reported as an efficient CT contrast agent to bridge CT diagnostic imaging with therapeutic intervention. PIDA has a high iodine payload (>84 wt%), and the aggregation of nanofibrous PIDA can further amplify CT intensity and has improved geometrical and positional stability in vivo. Moreover, with a conjugated backbone, PIDA is in deep blue color, making it dually visible by both CT imaging and the naked eyes. The performance of PIDA in CT-guided preoperative planning and visualization-guided surgery is validated using orthotopic xenograft rat models. In addition, PIDA excels clinical fiducial markers of imaging-guided radiotherapy in efficiency and biocompatibility, and exhibits successful guidance of robotic radiotherapy on Beagles, demonstrating clinical potential to translate CT diagnosis accuracy into therapeutic intervention for precision medicine.
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Casutt A, Kinj R, Ozsahin EM, von Garnier C, Lovis A. Fiducial markers for stereotactic lung radiation therapy: review of the transthoracic, endovascular and endobronchial approaches. Eur Respir Rev 2022; 31:31/163/210149. [PMID: 35022258 DOI: 10.1183/16000617.0149-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 09/09/2021] [Indexed: 11/05/2022] Open
Abstract
Stereotactic body radiation therapy is an alternative to surgery for early-stage, inoperable peripheral non-small cell lung cancer. As opposed to linear accelerator (linac)-based (e.g. gating) and free-breathing techniques, CyberKnife® with Synchrony® technology allows accurate radiation delivery by means of a real-time respiratory motion tracking system using, in most cases, metal fiducial markers (FMs) placed in the vicinity of the target. The aims of this review are as follows. First, to describe the safety and efficacy of the transthoracic, endovascular and endobronchial FM insertion techniques for peripheral pulmonary lesions (PPLs). Second, to analyse performance in terms of the migration and tracking rates of different FM types. Recent developments in FM tracking for central lesions will also be reviewed. In conclusion, for PPLs, the endobronchial approach provides a low rate of pneumothorax, offers the possibility of concurrent diagnostic sampling for both the PPL and the lymph nodes, and, finally, reduces the intervention time compared to other techniques. In this context, coil-tailed and coil-spring FMs have shown the lowest migration rate with a consequently high tracking rate.
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Affiliation(s)
- Alessio Casutt
- Division of Pulmonary Medicine, University Hospital of Lausanne, CHUV, Lausanne, Switzerland .,University of Lausanne, UNIL, Lausanne, Switzerland
| | - Rémy Kinj
- University of Lausanne, UNIL, Lausanne, Switzerland.,Dept of Radiation Oncology, University Hospital of Lausanne, CHUV, Lausanne, Switzerland
| | - Esat-Mahmut Ozsahin
- University of Lausanne, UNIL, Lausanne, Switzerland.,Dept of Radiation Oncology, University Hospital of Lausanne, CHUV, Lausanne, Switzerland
| | - Christophe von Garnier
- Division of Pulmonary Medicine, University Hospital of Lausanne, CHUV, Lausanne, Switzerland.,University of Lausanne, UNIL, Lausanne, Switzerland
| | - Alban Lovis
- Division of Pulmonary Medicine, University Hospital of Lausanne, CHUV, Lausanne, Switzerland.,University of Lausanne, UNIL, Lausanne, Switzerland
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Kord M, Kluge A, Kufeld M, Kalinauskaite G, Loebel F, Stromberger C, Budach V, Gebauer B, Acker G, Senger C. Risks and Benefits of Fiducial Marker Placement in Tumor Lesions for Robotic Radiosurgery: Technical Outcomes of 357 Implantations. Cancers (Basel) 2021; 13:cancers13194838. [PMID: 34638321 PMCID: PMC8508340 DOI: 10.3390/cancers13194838] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/19/2021] [Accepted: 09/22/2021] [Indexed: 12/15/2022] Open
Abstract
Simple Summary Robotic radiosurgery (RRS) allows for the accurate treatment of primary tumors or metastases with high single doses. However, organ motion during or between fractions can lead to imprecise irradiation. We sought to evaluate the risks and advantages of fiducial marker (FM) implantation regarding clinical complications, marker migration, and motion amplitude. Complications were most common in Synchrony®-tracked lesions affected by respiratory motion, particularly lung lesions. Pneumothoraces and pulmonary bleeding were the most common complications. An increased complication rate was associated with concomitant biopsy sampling and FM implantation. Most FM migration observed in this study occurred after CT-guided placements and clinical FM insertions. The largest motion amplitudes were observed in hepatic and lower lung lobe lesions. This study highlights the benefits of marker implantation, especially in lesions with a large motion amplitude, including hepatic lesions and lesions of the lower lobe of the lung located >100.0 mm from the spine. Abstract Fiducial markers (FM) inserted into tumors increase the precision of irradiation during robotic radiosurgery (RRS). This retrospective study evaluated the clinical complications, marker migration, and motion amplitude of FM implantations by analyzing 288 cancer patients (58% men; 63.1 ± 13.0 years) who underwent 357 FM implantations prior to RRS with CyberKnife, between 2011 and 2019. Complications were classified according to the Society of Interventional Radiology (SIR) guidelines. The radial motion amplitude was calculated for tumors that moved with respiration. A total of 725 gold FM was inserted. SIR-rated complications occurred in 17.9% of all procedures. Most complications (32.0%, 62/194 implantations) were observed in Synchrony®-tracked lesions affected by respiratory motion, particularly in pulmonary lesions (46.9% 52/111 implantations). Concurrent biopsy sampling was associated with a higher complication rate (p = 0.001). FM migration occurred in 3.6% after CT-guided and clinical FM implantations. The largest motion amplitudes were observed in hepatic (20.5 ± 11.0 mm) and lower lung lobe (15.4 ± 10.5 mm) lesions. This study increases the awareness of the risks of FM placement, especially in thoracic lesions affected by respiratory motion. Considering the maximum motion amplitude, FM placement remains essential in hepatic and lower lung lobe lesions located >100.0 mm from the spine.
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Affiliation(s)
- Melina Kord
- Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (A.K.); (G.K.); (C.S.); (V.B.)
- Charité CyberKnife Center, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (F.L.); (G.A.)
| | - Anne Kluge
- Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (A.K.); (G.K.); (C.S.); (V.B.)
- Charité CyberKnife Center, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (F.L.); (G.A.)
| | - Markus Kufeld
- Charité CyberKnife Center, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (F.L.); (G.A.)
| | - Goda Kalinauskaite
- Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (A.K.); (G.K.); (C.S.); (V.B.)
- Charité CyberKnife Center, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (F.L.); (G.A.)
| | - Franziska Loebel
- Charité CyberKnife Center, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (F.L.); (G.A.)
- Department of Neurosurgery, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117 Berlin, Germany
| | - Carmen Stromberger
- Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (A.K.); (G.K.); (C.S.); (V.B.)
- Charité CyberKnife Center, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (F.L.); (G.A.)
| | - Volker Budach
- Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (A.K.); (G.K.); (C.S.); (V.B.)
- Charité CyberKnife Center, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (F.L.); (G.A.)
| | - Bernhard Gebauer
- Department of Radiology, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117 Berlin, Germany;
| | - Gueliz Acker
- Charité CyberKnife Center, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (F.L.); (G.A.)
- Department of Neurosurgery, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117 Berlin, Germany
- Berlin Institute of Health at Charité Universitätsmedizin Berlin, BIH Acadamy, Clinician Scientist Program, Charitéplatz 1, 10117 Berlin, Germany
| | - Carolin Senger
- Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (A.K.); (G.K.); (C.S.); (V.B.)
- Charité CyberKnife Center, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (F.L.); (G.A.)
- Correspondence: ; Tel.: +49-30-450-557221
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Shah PL. Springs that don't spring out: Fiducials for stereotactic radiotherapy. Respirology 2021; 26:409-410. [PMID: 33749090 DOI: 10.1111/resp.14040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 03/08/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Pallav L Shah
- Department of Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust, London, UK.,Department of Respiratory Medicine, Chelsea and Westminster NHS Foundation Trust, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK
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