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Towell V, Gysen KV, Cross S, KK Low G. Efficacy of preoxygenation administration in volunteers, in extending the end-expiration breath-hold duration for application to abdominal radiotherapy. Tech Innov Patient Support Radiat Oncol 2023; 26:100208. [PMID: 37207259 PMCID: PMC10189463 DOI: 10.1016/j.tipsro.2023.100208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 04/02/2023] [Accepted: 04/18/2023] [Indexed: 05/21/2023] Open
Abstract
Background and purpose End expiration breath hold (EEBH) is the preferred motion management method for abdominal Stereotactic Ablative Body Radiotherapy (SABR) treatments. However, multiple short EEBHs are required to complete a single treatment session. The study aimed to determine the efficacy of preoxygenation with hyperventilation in extending an EEBH duration. Materials and methods We randomised 10 healthy participants into two arms, each included breathing room air and oxygen at a rate of 10 L per minute (l/min) without hyperventilation for four minutes, and normally for four minutes and with hyperventilation for one minute at a rate of 20 breaths/minute for hyperventilation. The type of gas was blinded from the participants for each test. EEBH durations were then recorded, as well as systolic blood pressure, SpO2 and heart rate. A discomfort rating was also recorded after each breath hold. Results A significant increase in duration of almost 50% was observed between normal breathing of room air and breathing oxygen normally followed by hyperventilation. Vital signs remained consistent between the 4 tests. The tests were well tolerated with 75% of participants recording none or minimal discomfort. Conclusion Preoxygenation with hyperventilation could be used to increase the EEBH duration for abdominal SABR patients which would assist in the accuracy of these treatments and possibly resulting in a reduction of overall treatment times.
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Affiliation(s)
- Vincent Towell
- Department of Radiation Oncology, Nepean Hospital Cancer Care Centre, Sydney, Australia
- Corresponding author.
| | - Kirsten Van Gysen
- Department of Radiation Oncology, Nepean Hospital Cancer Care Centre, Sydney, Australia
- Nepean Clinical School, University of Sydney, Sydney, Australia
| | - Shamira Cross
- Department of Radiation Oncology, Nepean Hospital Cancer Care Centre, Sydney, Australia
- Nepean Clinical School, University of Sydney, Sydney, Australia
| | - Gary KK Low
- Research Operations, Nepean Hospital, Sydney, Australia
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
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Zhang Y, Trnkova P, Toshito T, Heijmen B, Richter C, Aznar M, Albertini F, Bolsi A, Daartz J, Bertholet J, Knopf A. A survey of practice patterns for real-time intrafractional motion-management in particle therapy. Phys Imaging Radiat Oncol 2023; 26:100439. [PMID: 37124167 PMCID: PMC10133874 DOI: 10.1016/j.phro.2023.100439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/05/2023] [Accepted: 04/06/2023] [Indexed: 05/02/2023] Open
Abstract
Background and purpose Organ motion compromises accurate particle therapy delivery. This study reports on the practice patterns for real-time intrafractional motion-management in particle therapy to evaluate current clinical practice and wishes and barriers to implementation. Materials and methods An institutional questionnaire was distributed to particle therapy centres worldwide (7/2020-6/2021) asking which type(s) of real-time respiratory motion management (RRMM) methods were used, for which treatment sites, and what were the wishes and barriers to implementation. This was followed by a three-round DELPHI consensus analysis (10/2022) to define recommendations on required actions and future vision. With 70 responses from 17 countries, response rate was 100% for Europe (23/23 centres), 96% for Japan (22/23) and 53% for USA (20/38). Results Of the 68 clinically operational centres, 85% used RRMM, with 41% using both rescanning and active methods. Sixty-four percent used active-RRMM for at least one treatment site, mostly with gating guided by an external marker. Forty-eight percent of active-RRMM users wished to expand or change their RRMM technique. The main barriers were technical limitations and limited resources. From the DELPHI analysis, optimisation of rescanning parameters, improvement of motion models, and pre-treatment 4D evaluation were unanimously considered clinically important future focus. 4D dose calculation was identified as the top requirement for future commercial treatment planning software. Conclusion A majority of particle therapy centres have implemented RRMM. Still, further development and clinical integration were desired by most centres. Joint industry, clinical and research efforts are needed to translate innovation into efficient workflows for broad-scale implementation.
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Affiliation(s)
- Ye Zhang
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
| | - Petra Trnkova
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | - Toshiyuki Toshito
- Nagoya Proton Therapy Center, Nagoya City University West Medical Center, Nagoya, Japan
| | - Ben Heijmen
- Department of Radiotherapy, Erasmus University Medical Center (Erasmus MC), Rotterdam, the Netherlands
| | - Christian Richter
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
| | - Marianne Aznar
- Faculty of Biology, Medicine and Health, Division of Cancer Sciences, University of Manchester, United Kingdom
| | | | - Alexandra Bolsi
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
| | - Juliane Daartz
- F. Burr Proton Therapy, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | - Jenny Bertholet
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Antje Knopf
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
- Institute for Medical Engineering and Medical Informatics, School of Life Science FHNW, Muttenz, Switzerland
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Appel S, Lawrence YR, Bar J, Jacobson G, Marom EM, Katzman T, Ben-Ayun M, Dubinski S, Haisraely O, Weizman N, Davidson T, Weiss I, Mansano A, Goldstein JD, Symon Z. Deep inspiratory breath hold assisted by continuous positive airway pressure ventilation for lung stereotactic body radiotherapy. Cancer Radiother 2023; 27:23-30. [PMID: 36057519 DOI: 10.1016/j.canrad.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 05/14/2022] [Accepted: 05/24/2022] [Indexed: 02/06/2023]
Abstract
PURPOSE Continuous positive airway pressure (CPAP) ventilation hyperinflates the lungs and reduces diaphragmatic motion. We hypothesized that CPAP could be safely combined with deep inspiratory breath hold (CPAP-DIBH) during lung stereotactic radiotherapy (SBRT). MATERIAL AND METHODS Patients with stage-1 lung cancer or lung metastasis treated with CPAP-DIBH SBRT between 3/2017-5/2021 were analyzed retrospectively. Patient characteristics, treatment parameters, duration of breath holds in all sessions and tolerance to CPAP-DIBH were recorded. Local control (LC) was assessed from CT or PET-CT imaging. The distances between the tumor and mediastinal organs at risk (OAR) in centrally located tumors using either free breathing (FB) or CPAP-DIBH were compared. Toxicity was graded retrospectively. RESULTS Forty-five patients with 71 lesions were treated with CPAP-DIBH SBRT. Indications for CPAP-DIBH were prior radiation (35/71, 65%), lower lobe location (34/71, 48%), multiple lesions (26/71, 36.6%) and proximity to mediastinal OAR (7/71, 10%). Patient characteristics were: F:M 43%: 57%; mean gross tumor volume 4.5cm3 (SD 7.9), mean planning target volume 20cm3 (SD 27), primary: metastatic lesions (7%:93%). Mean radiation dose was 52.5 Gray (SD3.5). Mean lung volume was 5292cm3 (SD 1106). Mean duration of CPAP-DIBH was 41.3s (IQR 31-46.8). LC at 2 years was 89.5% (95% CI 76-95.5). In patients with central lesions, the distance between the tumor and mediastinal OAR increased from 0.84cm (SD 0.65) with FB to 1.23cm (SD 0.8) with CPAP-DIBH (p=0.002). Most patients tolerated CPAP well and completed all treatments after starting therapy. Three patients did not receive treatment: 2 were unable to tolerate CPAP and 1 had syncope (pre-existing). Toxicity was grade 2 in 4/65 (6%) and grade 3 in 1/65 (1.5%). There was no grade 2 or higher esophageal or tracheal toxicities. CONCLUSION CPAP-DIBH assisted lung SBRT was tolerated well and was associated with minimal toxicity and favorable LC. This technique may be considered when treating multiple lung lesions, lesions located in the lower lobes or adjacent to mediastinal OAR.
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Affiliation(s)
- Sarit Appel
- Department of Radiation Oncology, Sheba Medical Center, Tel Hashomer, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Yaacov Richard Lawrence
- Department of Radiation Oncology, Sheba Medical Center, Tel Hashomer, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jair Bar
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Institute of Oncology, Sheba Medical Center, Tel Hashomer, Israel
| | - Galia Jacobson
- Department of Radiation Oncology, Sheba Medical Center, Tel Hashomer, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Edith M Marom
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Radiology, Sheba Medical Center, Tel Hashomer, Israel
| | - Tamar Katzman
- Department of Radiation Oncology, Sheba Medical Center, Tel Hashomer, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Maoz Ben-Ayun
- Department of Radiation Oncology, Sheba Medical Center, Tel Hashomer, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sergei Dubinski
- Department of Radiation Oncology, Sheba Medical Center, Tel Hashomer, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ory Haisraely
- Department of Radiation Oncology, Sheba Medical Center, Tel Hashomer, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Noam Weizman
- Department of Radiation Oncology, Hadassah Medical Center, Jerusalem, Israel
| | - Tima Davidson
- Nuclear Medicine, Sheba Medical Center, Tel Hashomer, Israel
| | - Ilana Weiss
- Department of Radiation Oncology, Sheba Medical Center, Tel Hashomer, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anat Mansano
- Department of Radiation Oncology, Sheba Medical Center, Tel Hashomer, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Zvi Symon
- Department of Radiation Oncology, Sheba Medical Center, Tel Hashomer, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Mireştean CC, Iancu RI, Iancu DPT. Hypofractionated Whole-Breast Irradiation Focus on Coronary Arteries and Cardiac Toxicity-A Narrative Review. Front Oncol 2022; 12:862819. [PMID: 35463375 PMCID: PMC9021451 DOI: 10.3389/fonc.2022.862819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 03/10/2022] [Indexed: 11/17/2022] Open
Abstract
Breast cancer is the most common cancer among women worldwide, which is often treated with radiotherapy. Whole breast irradiation (WBI) is one of the most common types of irradiation. Hypo-fractionated WBI (HF-WBI) reduces the treatment time from 5 to 3 weeks. Recent radiobiological and clinical evidence recommended the use of HF-WBI regardless of the age or stage of disease, and it is proven that hypo-fractionation is non-inferior to conventional fractionation regimen irradiation. However, some studies report an increased incidence of heart-related deaths in the case of breast irradiation by hypo-fractionation, especially in patients with pre-existing cardiac risk factors at the time of treatment. Due to the new technical possibilities of radiotherapy techniques, HF-WBI can reduce the risk of cardiac toxicity by controlling the doses received both by the heart and by the anatomical structures of the heart. The radiobiological “double trouble”, in particular “treble trouble”, for hypo-fractionated regimen scan be avoided by improving the methods of heart sparing based on image-guided irradiation (IGRT) and by using respiration control techniques so that late cardiac toxicity is expected to be limited. However, long-term follow-up of patients treated with HF-WBI with modern radiotherapy techniques is necessary considering the progress of systemic therapy, which is associated with long-term survival, and also the cardiac toxicity of new oncological treatments. The still unknown effects of small doses spread in large volumes on lung tissue may increase the risk of second malignancy, but they can also be indirectly involved in the later development of a heart disease. It is also necessary to develop multivariable radiobiological models that include histological, molecular, clinical, and therapeutic parameters to identify risk groups and dosimetric tolerance in order to limit the incidence of late cardiac events. MR-LINAC will be able to offer a new standard for reducing cardiac toxicity in the future, especially in neoadjuvant settings for small tumors.
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Affiliation(s)
- Camil Ciprian Mireştean
- Department of Medical Oncology and Radiotherapy, University of Medicine and Pharmacy Craiova, Craiova, Romania.,Department of Surgery, Railways Clinical Hospital, Iasi, Romania
| | - Roxana Irina Iancu
- Oral Pathology Department, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania.,Department of Clinical Laboratory, St. Spiridon Emergency Hospital, Iaşi, Romania
| | - Dragoş Petru Teodor Iancu
- Department of Medical Oncology and Radiotherapy Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania.,Department of Radiation Oncology, Regional Institute of Oncology, Iasi, Romania
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Parkes MJ, Green S, Cashmore J, Ghafoor Q, Clutton-Brock T. Shortening the preparation time of the single prolonged breath-hold for radiotherapy sessions. Br J Radiol 2021; 95:20210408. [PMID: 34930022 PMCID: PMC8822572 DOI: 10.1259/bjr.20210408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Objective: Single prolonged breath-holds of >5 min can be obtained in cancer patients. Currently, however, the preparation time in each radiotherapy session is a practical limitation for clinical adoption of this new technique. Here, we show by how much our original preparation time can be shortened without unduly compromising breath-hold duration. Methods: 44 healthy subjects performed single prolonged breath-holds from 60% O2 and mechanically induced hypocapnia. We tested the effect on breath-hold duration of shortening preparation time (the durations of acclimatization, hyperventilation and hypocapnia) by changing these durations and or ventilator settings. Results: Mean original breath-hold duration was 6.5 ± 0.2 (standard error) min. The total original preparation time (from connecting the facemask to the start of the breath-hold) was 26 ± 1 min. After shortening the hypocapnia duration from 16 to 5 min, mean breath-hold duration was still 6.1 ± 0.2 min (ns vs the original). After abolishing the acclimatization and shortening the hypocapnia to 1 min (a total preparation time now of 9 ± 1 min), a mean breath-hold duration of >5 min was still possible (now significantly shortened to 5.2 ± 0.6 min, p < 0.001). After shorter and more vigorous hyperventilation (lasting 2.7 ± 0.3 min) and shorter hypocapnia (lasting 43 ± 4 s), a mean breath-hold duration of >5 min (5.3 ± 0.2 min, p < 0.05) was still possible. Here, the final total preparation time was 3.5 ± 0.3 min. Conclusions: These improvements may facilitate adoption of the single prolonged breath-hold for a range of thoracic and abdominal radiotherapies especially involving hypofractionation. Advances in knowledge: Multiple short breath-holds improve radiotherapy for thoracic and abdominal cancers. Further improvement may occur by adopting the single prolonged breath-hold of >5 min. One limitation to clinical adoption is its long preparation time. We show here how to reduce the mean preparation time from 26 to 3.5 min without compromising breath-hold duration
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Affiliation(s)
- Michael John Parkes
- School of Sport, Exercise & Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom.,National Institute for Health Research (NIHR)/Wellcome Trust Birmingham Clinical Research Facility, Birmingham, United Kingdom.,Hall Edwards Radiotherapy Group, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.,Marie Sklodowska-Curie Fellow, Department of Radiation Oncology, University Medical Centre, Amsterdam, Netherlands
| | - Stuart Green
- Hall Edwards Radiotherapy Group, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Jason Cashmore
- Hall Edwards Radiotherapy Group, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Qamar Ghafoor
- Hall Edwards Radiotherapy Group, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Thomas Clutton-Brock
- National Institute for Health Research (NIHR)/Wellcome Trust Birmingham Clinical Research Facility, Birmingham, United Kingdom.,Department of Anaesthesia and Intensive Care Medicine, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
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Parkes MJ, De Neve W, Vakaet V, Heyes G, Jackson T, Delaney R, Kirby G, Green S, Kilby W, Cashmore J, Ghafoor Q, Clutton-Brock T. Safely achieving single prolonged breath-holds of > 5 minutes for radiotherapy in the prone, front crawl position. Br J Radiol 2021; 94:20210079. [PMID: 33914612 PMCID: PMC8173692 DOI: 10.1259/bjr.20210079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Breast cancer radiotherapy is increasingly delivered supine with multiple, short breath-holds. There may be heart and lung sparing advantages for locoregional breast cancer of both prone treatment and in a single breath-hold. We test here whether single prolonged breath-holds are possible in the prone, front crawl position. METHODS 19 healthy volunteers were trained to deliver supine, single prolonged breath-holds with pre-oxygenation and hypocapnia. We tested whether all could achieve the same durations in the prone, front crawl position. RESULTS 19 healthy volunteers achieved supine, single prolonged breath-holds for mean of 6.2 ± 0.3 min. All were able to hold safely for the same duration while prone (6.1 ± 0.2 min ns. by paired ANOVA). With prone, the increased weight on the chest did not impede chest inflation, nor the ability to hold air in the chest. Thus, the rate of chest deflation (mean anteroposterior deflation movement of three craniocaudally arranged surface markers on the spinal cord) was the same (1.2 ± 0.2, 2.0 ± 0.4 and 1.2 ± 0.4 mm/min) as found previously during supine prolonged breath-holds. No leakage of carbon dioxide or air was detectable into the facemask. CONCLUSION Single prolonged (>5 min) breath-holds are equally possible in the prone, front crawl position. ADVANCES IN KNOWLEDGE Prolonged breath-holds in the front crawl position are possible and have the same durations as in the supine position. Such training would therefore be feasible for some patients with breast cancer requiring loco-regional irradiation. It would have obvious advantages for hypofractionation.
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Affiliation(s)
- M J Parkes
- School of Sport, Exercise & Rehabilitation Sciences, Birmingham, UK.,National Institute for Health Research (NIHR)/Wellcome Trust Birmingham Clinical Research Facility, Birmingham, UK.,Hall Edwards Radiotherapy Group, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Wilfried De Neve
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Vincent Vakaet
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Geoffrey Heyes
- Hall Edwards Radiotherapy Group, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Timothy Jackson
- Hall Edwards Radiotherapy Group, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard Delaney
- Hall Edwards Radiotherapy Group, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Gavin Kirby
- Hall Edwards Radiotherapy Group, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Stuart Green
- Hall Edwards Radiotherapy Group, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Jason Cashmore
- Hall Edwards Radiotherapy Group, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Qamar Ghafoor
- Hall Edwards Radiotherapy Group, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Thomas Clutton-Brock
- National Institute for Health Research (NIHR)/Wellcome Trust Birmingham Clinical Research Facility, Birmingham, UK.,Department of Anaesthesia and Intensive Care Medicine, University of Birmingham andUniversity Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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