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Loap P, Giorgi M, Vu-Bezin J, Kirov K, Sampai JM, Prezado Y, Kirova Y. Dosimetric feasibility study ("proof of concept") of refractory ventricular tachycardia radioablation using proton minibeams. Cancer Radiother 2024; 28:195-201. [PMID: 38599941 DOI: 10.1016/j.canrad.2024.02.002] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 02/15/2024] [Accepted: 02/16/2024] [Indexed: 04/12/2024]
Abstract
PURPOSE Preclinical data demonstrated that the use of proton minibeam radiotherapy reduces the risk of toxicity in healthy tissue. Ventricular tachycardia radioablation is an area under clinical investigation in proton beam therapy. We sought to simulate a ventricular tachycardia radioablation with proton minibeams and to demonstrate that it was possible to obtain a homogeneous coverage of an arrhythmogenic cardiac zone with this technique. MATERIAL AND METHODS An arrhythmogenic target volume was defined on the simulation CT scan of a patient, localized in the lateral wall of the left ventricle. A dose of 25Gy was planned to be delivered by proton minibeam radiotherapy, simulated using a Monte Carlo code (TOPAS v.3.7) with a collimator of 19 0.4 mm-wide slits spaced 3mm apart. The main objective of the study was to obtain a plan ensuring at least 93% of the prescription dose in 93% of the planning target volume without exceeding 110% of the prescribed dose in the planning target volume. RESULTS The average dose in the planning treatment volume in proton minibeam radiotherapy was 25.12Gy. The percentage of the planning target volume receiving 93% (V93%), 110% (V110%), and 95% (V95%) of the prescribed dose was 94.25%, 0%, and 92.6% respectively. The lateral penumbra was 6.6mm. The mean value of the peak-to-valley-dose ratio in the planning target volume was 1.06. The mean heart dose was 2.54Gy versus 5.95Gy with stereotactic photon beam irradiation. CONCLUSION This proof-of-concept study shows that proton minibeam radiotherapy can achieve a homogeneous coverage of an arrhythmogenic cardiac zone, reducing the dose at the normal tissues. This technique, ensuring could theoretically reduce the risk of late pulmonary and breast fibrosis, as well as cardiac toxicity as seen in previous biological studies in proton minibeam radiotherapy.
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Affiliation(s)
- P Loap
- Department of Radiation Oncology, institut Curie, Paris, France
| | - M Giorgi
- Signalisation radiobiologie et cancer, Inserm U1021, CNRS UMR3347, Institut Curie, université PSL, 91400 Orsay, France; Laboratório de Instrumentação e Física Experimental de Partículas (LIP), Lisboa, Portugal; Departamento de Física, Faculdade de Ciências, Universidade de Lisboa, Lisboa, Portugal
| | - J Vu-Bezin
- Department of Radiation Oncology, institut Curie, Paris, France
| | - K Kirov
- Department of Anesthesia and Reanimation, institut Curie, Paris, France
| | - J M Sampai
- Laboratório de Instrumentação e Física Experimental de Partículas (LIP), Lisboa, Portugal; Departamento de Física, Faculdade de Ciências, Universidade de Lisboa, Lisboa, Portugal
| | - Y Prezado
- Signalisation radiobiologie et cancer, Inserm U1021, CNRS UMR3347, Institut Curie, université PSL, 91400 Orsay, France
| | - Y Kirova
- Department of Radiation Oncology, institut Curie, Paris, France; Université Versailles, Saint-Quentin, France.
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Benali K, Zei PC, Lloyd M, Kautzner J, Guenancia C, Ninni S, Rigal L, Simon A, Bellec J, Vlachos K, Sacher F, Hammache N, Sellal JM, de Crevoisier R, Da Costa A, Martins R. One-year mortality and causes of death after stereotactic radiation therapy for refractory ventricular arrhythmias: A systematic review and pooled analysis. Trends Cardiovasc Med 2024:S1050-1738(23)00122-6. [PMID: 38191005 DOI: 10.1016/j.tcm.2023.12.008] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/25/2023] [Accepted: 12/27/2023] [Indexed: 01/10/2024]
Abstract
Patients treated with cardiac stereotactic body radiation therapy (radioablation) for refractory ventricular arrhythmias are patients with advanced structural heart disease and significant comorbidities. However, data regarding 1-year mortality after the procedure are scarce. This systematic review and pooled analysis aimed at determining 1-year mortality after cardiac radioablation for refractory ventricular arrhythmias and investigating leading causes of death in this population. MEDLINE/EMBASE databases were searched up to January 2023 for studies including patients undergoing cardiac radioablation for the treatment of refractory ventricular arrhythmias. Quality of included trials was assessed using the NIH Tool for Case Series Studies (PROSPERO CRD42022379713). A total of 1,151 references were retrieved and evaluated for relevance. Data were extracted from 16 studies, with a total of 157 patients undergoing cardiac radioablation for refractory ventricular arrhythmias. Pooled 1-year mortality was 32 % (95 %CI: 23-41), with almost half of the deaths occurring within three months after treatment. Among the 157 patients, 46 died within the year following cardiac radioablation. Worsening heart failure appeared to be the leading cause of death (52 %), although non-cardiac mortality remained substantial (41 %) in this population. Age≥70yo was associated with a significantly higher 12-month all-cause mortality (p<0.022). Neither target volume size nor radiotherapy device appeared to be associated with 1-year mortality (p = 0.465 and p = 0.199, respectively). About one-third of patients undergoing cardiac stereotactic body radiation therapy for refractory ventricular arrhythmias die within the first year after the procedure. Worsening heart failure appears to be the leading cause of death in this population.
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Affiliation(s)
- Karim Benali
- Section of Cardiac Electrophysiology, Saint-Etienne University, Saint-Etienne, France; IHU LIRYC, Electrophysiology and Heart Modeling Institute, Bordeaux, France; INSERM-LTSI, U1099 Rennes, France.
| | - Paul C Zei
- Department of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, United States
| | - Michael Lloyd
- Section of Cardiac Electrophysiology, Emory University, Atlanta, United States
| | - Josef Kautzner
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Charles Guenancia
- Section of Cardiac Electrophysiology, Dijon University, Dijon, France
| | - Sandro Ninni
- Heart and Lung Institute, Lille University, Lille, France
| | | | | | - Julien Bellec
- Department of Radiation Oncology, Centre Eugène Marquis, Rennes, France
| | | | - Frederic Sacher
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Bordeaux, France
| | - Nefissa Hammache
- Section of Cardiac Electrophysiology, Nancy University, Nancy, France
| | - Jean-Marc Sellal
- Section of Cardiac Electrophysiology, Nancy University, Nancy, France
| | | | - Antoine Da Costa
- Section of Cardiac Electrophysiology, Saint-Etienne University, Saint-Etienne, France
| | - Raphael Martins
- INSERM-LTSI, U1099 Rennes, France; Section of Cardiac Electrophysiology, Rennes University, Rennes, France
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Kawamura M, Shimojo M, Inden Y, Kamomae T, Okudaira K, Komada T, Aoki S, Shindo Y, Yasui R, Yanagi Y, Okumura M, Yamada T, Kozai Y, Oie Y, Kato Y, Ishihara S, Murohara T, Naganawa S. Stereotactic radiotherapy for ventricular tachycardia: A study protocol. F1000Res 2023; 12:798. [PMID: 38204487 PMCID: PMC10776963 DOI: 10.12688/f1000research.138758.2] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/07/2023] [Indexed: 01/12/2024] Open
Abstract
Background Currently, the standard curative treatment for ventricular tachycardia (VT) and ventricular fibrillation (VF) is radiofrequency catheter ablation. However, when the VT circuit is deep in the myocardium, the catheter may not be delivered, and a new, minimally invasive treatment using different energies is desired. Methods This is a protocol paper for a feasibility study designed to provide stereotactic radiotherapy for refractory VT not cured by catheter ablation after at least one catheter ablation. The primary end point is to evaluate the short-term safety of this treatment and the secondary endpoint is to evaluate its efficacy as assessed by the reduction in VT episode. Cyberknife M6 radiosurgery system will be used for treatment, and the prescribed dose to the target will be 25Gy in one fraction. The study will be conducted on three patients. Conclusion Since catheter ablation is the only treatment option for VT that is covered by insurance in Japan, there is currently no other treatment for VT/VF that cannot be cured by catheter ablation. We hope that this feasibility study will provide hope for patients who are currently under the stress of ICD activation. Trial registration The study has been registered in the Japan Registry of Clinical Trials (jRCTs042230030).
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Affiliation(s)
- Mariko Kawamura
- Radiology, Nagoya University Hospital, Nagoya, Aichi Prefecture, Japan
| | - Masafumi Shimojo
- Cardiology, Nagoya University Hospital, Nagoya, Aichi Prefecture, Japan
| | - Yasuya Inden
- Cardiology, Nagoya University Hospital, Nagoya, Aichi Prefecture, Japan
| | - Takeshi Kamomae
- Radiology, Nagoya University Hospital, Nagoya, Aichi Prefecture, Japan
| | - Kuniyasu Okudaira
- Radiological Technology, Nagoya University Hospital, Nagoya, Aichi Prefecture, Japan
| | - Tomohiro Komada
- Radiology, Nagoya University Hospital, Nagoya, Aichi Prefecture, Japan
| | - Sumire Aoki
- Radiology, Nagoya University Hospital, Nagoya, Aichi Prefecture, Japan
| | - Yurika Shindo
- Radiology, Nagoya University Hospital, Nagoya, Aichi Prefecture, Japan
| | - Ryotaro Yasui
- Radiology, Nagoya University Hospital, Nagoya, Aichi Prefecture, Japan
| | - Yusuke Yanagi
- Radiology, Nagoya University Hospital, Nagoya, Aichi Prefecture, Japan
| | - Masayuki Okumura
- Radiology, Nagoya University Hospital, Nagoya, Aichi Prefecture, Japan
| | - Takehiro Yamada
- Radiology, Nagoya University Hospital, Nagoya, Aichi Prefecture, Japan
| | - Yuka Kozai
- Radiology, Nagoya University Hospital, Nagoya, Aichi Prefecture, Japan
| | - Yumi Oie
- Radiology, Nagoya University Hospital, Nagoya, Aichi Prefecture, Japan
| | - Yutaka Kato
- Radiological Technology, Nagoya University Hospital, Nagoya, Aichi Prefecture, Japan
| | - Shunichi Ishihara
- Radiology, Nagoya University Hospital, Nagoya, Aichi Prefecture, Japan
| | - Toyoaki Murohara
- Cardiology, Nagoya University Hospital, Nagoya, Aichi Prefecture, Japan
| | - Shinji Naganawa
- Radiology, Nagoya University Hospital, Nagoya, Aichi Prefecture, Japan
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Öztürk HF, Arslan SA, Gani Z, Aras D, Tezcan Y. From organ at risk to target organ: Dosimetric comparison of myocardial stereotactic ablative body radiotherapy between helical tomotherapy and volumetric arc therapy for refractory ventricular tachycardia. Med Dosim 2023; 48:293-298. [PMID: 37673728 DOI: 10.1016/j.meddos.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 06/19/2023] [Accepted: 08/03/2023] [Indexed: 09/08/2023]
Abstract
Ventricular tachycardia (VT) is an important type of arrhythmia with a risk of sudden death. Although implanted cardiac defibrillation and radiofrequency ablation are used together with medical treatments for VT, the treatment options are limited in cases that do not respond to them. Stereotactic ablative body radiotherapy (SABR) applied to VT substrates in resistant cases is an emerging treatment with positive results. Such clinical results have increased the interest in this subject. However, the ideal treatment device and method have not yet been described for this therapy, which is generally applied at a single fraction using various devices and methods. Herein, treatment planning was conducted for a total of 8 patients (11 VT substrates) using the Varian TrueBeam EDGE and TomoTherapy Radixact devices at a single center, and the results were compared dosimetrically. The Wilcoxon-signed rank test was used for the statistical analysis, and mean values were expressed as medians and interquartile ranges (IQRs). In the volumetric modulated arc therapy (VMAT) and helical tomotherapy (HT) plans, the plan coverages and conformity indexes were similar; meanwhile, the homogeneity indexes were 0.10 (IQR = 0.05) and 0.07 (IQR = 0.05), respectively, and were significantly better in the HT plan (p = 0.02). The gradient indexes were 3.18 (IQR = 0.8) and 5.33 (IQR = 3.68) in the VMAT and HT plans, respectively, and were significantly better in the VMAT plan. For the organs at risk, similar doses were observed. The maximum doses for the stomach and esophagus and the mean doses for the left lung and both lungs were significantly lower in the VMAT plan. Similarly, the maximum and mean doses for the cardiac substructures and great vessels were significantly lower in the VMAT plan. More homogeneous plans were obtained in HT, while a faster dose reduction and lower critical organ dose were observed in VMAT. Reasonable myocardial SABR plans could be obtained with both techniques. The effects of the dosimetric differences on the clinical outcomes should be evaluated in prospective clinical studies.
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Affiliation(s)
- Hüseyin Furkan Öztürk
- Department of Radiation Oncology, Yıldırım Beyazıt University, Ankara 06800, Turkey.
| | - Suheyla Aytaç Arslan
- Department of Radiation Oncology, Yıldırım Beyazıt University, Ankara 06800, Turkey
| | - Zerrin Gani
- Department of Radiation Oncology, Ankara Bilkent City Hospital, Ankara 06800, Turkey
| | - Dursun Aras
- Department of Cardiology, İstanbul Medipol University Bahçelievler Hospital, Istanbul 34196, Turkey
| | - Yılmaz Tezcan
- Department of Radiation Oncology, Yıldırım Beyazıt University, Ankara 06800, Turkey
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Lydiard S, Pontré B, Hindley N, Lowe BS, Sasso G, Keall P. MRI-guided cardiac-induced target motion tracking for atrial fibrillation cardiac radioablation. Radiother Oncol 2021; 164:138-145. [PMID: 34597739 DOI: 10.1016/j.radonc.2021.09.025] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 09/13/2021] [Accepted: 09/22/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND PURPOSE Atrial fibrillation (AF) cardiac radioablation (CR) challenges radiotherapy tracking: multiple small targets close to organs-at-risk undergo rapid differential cardiac contraction and respiratory motion. MR-guidance offers a real-time target tracking solution. This work develops and investigates MRI-guided tracking of AF CR targets with cardiac-induced motion. MATERIALS AND METHODS A direct tracking method (Trackingdirect) and two indirect tracking methods leveraging population-based surrogacy relationships with the left atria (Trackingindirect_LA) or other target (Trackingindirect_target) were developed. Tracking performance was evaluated using transverse ECG-gated breathhold MRI images from 15 healthy and 10 AF participants. Geometric and volumetric tracking errors were calculated, defined as the difference between the ground-truth and tracked target centroids and volumes respectively. Transverse, breath-hold, noncardiac-gated cine images were acquired at 4 Hz in 5 healthy and 5 AF participants to qualitatively characterize tracking performance on images more comparable to MRILinac acquisitions. RESULTS The average 3D geometric tracking errors for Trackingdirect, Trackingindirect_LA and Trackingindirect_target respectively were 1.7 ± 1.2 mm, 1.6 ± 1.1 mm and 1.9 ± 1.3 mm in healthy participants and 1.7 ± 1.3 mm, 1.5 ± 1.0 mm and 1.7 ± 1.2 mm in AF participants. For Trackingdirect, 88% of analyzed images had 3D geometric tracking errors <3 mm and the average volume tracking error was 1.7 ± 1.3 cc. For Trackingdirect on non-cardiac-gated cine images, tracked targets overlapped organsat-risk or completely missed the target area on 2.2% and 0.08% of the images respectively. CONCLUSION The feasibility of non-invasive MRI-guided tracking of cardiac-induced AF CR target motion was demonstrated for the first time, showing potential for improving AF CR treatment efficacy.
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Affiliation(s)
- Suzanne Lydiard
- ACRF Image X Institute, University of Sydney, Eveleigh, Australia.
| | - Beau Pontré
- Department of Anatomy and Medical Imaging, University of Auckland, New Zealand
| | - Nicholas Hindley
- ACRF Image X Institute, University of Sydney, Eveleigh, Australia
| | - Boris S Lowe
- Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand
| | - Giuseppe Sasso
- Department of Anatomy and Medical Imaging, University of Auckland, New Zealand; Radiation Oncology Department, Auckland City Hospital, New Zealand; Department of Oncology, University of Auckland, New Zealand
| | - Paul Keall
- ACRF Image X Institute, University of Sydney, Eveleigh, Australia
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6
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Krug D, Blanck O, Andratschke N, Guckenberger M, Jumeau R, Mehrhof F, Boda-Heggemann J, Seidensaal K, Dunst J, Pruvot E, Scholz E, Saguner AM, Rudic B, Boldt LH, Bonnemeier H. Recommendations regarding cardiac stereotactic body radiotherapy for treatment refractory ventricular tachycardia. Heart Rhythm 2021; 18:2137-2145. [PMID: 34380072 DOI: 10.1016/j.hrthm.2021.08.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 08/02/2021] [Accepted: 08/03/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Ventricular tachycardia (VT) is a potentially lethal complication of structural heart disease. Despite optimal management, a subgroup of patients continue to suffer from recurrent VT. Recently, cardiac stereotactic body radiotherapy (CSBRT) has been introduced as a treatment option in patients with VT refractory to antiarrhythmic drugs and catheter ablation. OBJECTIVE The purpose of this study was to establish an expert consensus regarding the conduct and use of CSBRT for refractory VT. METHODS We conducted a modified Delphi process. Thirteen experts from institutions from Germany and Switzerland participated in the modified Delphi process. Statements regarding the following topics were generated: treatment setting, institutional expertise and technical requirements, patient selection, target volume definition, and monitoring during and after CSBRT. Agreement was rated on a 5-point Likert scale. Cutoffs for agreement were defined in analogy to the RAND methodology. RESULTS There was strong agreement regarding the experimental status of the procedure and the preference for treatment in clinical trials. CSBRT should be conducted at specialized centers with a strong expertise in the management of patients with ventricular arrhythmias and in stereotactic body radiotherapy for moving targets. CSBRT should be restricted to patients with refractory VT with optimal antiarrhythmic medication who underwent prior catheter ablation or have contraindications. Target volume delineation for CSBRT is complex. Therefore, interdisciplinary processes that should include cardiology/electrophysiology and radiation oncology as well as medical physics, radiology, and nuclear medicine are needed. Optimal follow-up is required. CONCLUSION Prospective trials and pooled registries are needed to gain further insight into this promising treatment option for patients with refractory VT.
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Affiliation(s)
- David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany.
| | - Oliver Blanck
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | | | - Raphael Jumeau
- Department of Radiation Oncology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; Radiation Oncology Institute, Hirslanden Clinique Bois-Cerf, Lausanne, Switzerland
| | - Felix Mehrhof
- Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Judit Boda-Heggemann
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Medical Faculty Mannheim, Mannheim, Germany
| | - Katharina Seidensaal
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
| | - Jürgen Dunst
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Etienne Pruvot
- Heart and Vessel Department, Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Eberhard Scholz
- Department of Cardiology, Heidelberg Center for Heart Rhythm Disorders (HCR), University of Heidelberg, Heidelberg, Germany
| | - Ardan M Saguner
- Department of Cardiology, University Heart Center Zurich, Zurich, Switzerland
| | - Boris Rudic
- Department of Internal Medicine I, Section for Electrophysiology und Rhythmology, University Medical Center Mannheim, University of Heidelberg, Medical Faculty Mannheim, Mannheim, Germany
| | - Leif-Hendrik Boldt
- Department of Internal Medicine and Cardiology, Charité University Medicine Berlin-Campus Virchow Klinikum, Berlin, Germany
| | - Hendrik Bonnemeier
- Department of Internal Medicine III, Section for Electrophysiology und Rhythmology, University Hospital Schleswig-Holstein, Kiel, Germany
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7
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Shoji M, Inaba K, Itami J, Hamada M, Okamoto H, Iwasa T, Ushigusa T, Yoshida M, Matsuyama TA, Otsuka T, Kumagai K, Hirao K, Maguire P, Qian P, Gardner E, Zei PC. Advantages and challenges for noninvasive atrial fibrillation ablation. J Interv Card Electrophysiol 2020; 62:319-327. [PMID: 33106957 DOI: 10.1007/s10840-020-00904-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 10/21/2020] [Indexed: 12/31/2022]
Abstract
PURPOSE Although catheter ablation is an effective therapy for atrial fibrillation (AF), risks remain and improved efficacy is desired. Stereotactic radiotherapy is a well-established therapy used to noninvasively treat malignancies with precision. We sought to evaluate stereotactic arrhythmia radioablation (STAR) as a therapeutic option for treating AF. METHODS AND RESULTS Three cancer patients with drug refractory AF were enrolled. Planning software using 3-D CT of the left atrium was used to design a desired ablation volume encompassing antral circumferential pulmonary vein isolation, roof and floor lines to create a "box" lesion set. After planning, patients were treated in the radioablation suite. STAR was able to deliver the intended radiation dose to the target in all 3 patients. No complications were observed over a follow-up period of 24 months. One patient with paroxysmal AF died from deterioration of cancer. The autopsy revealed evidence of fibroblasts and fibrogenesis in the region of atrial tissues targeted with radioablation. In one of these patients, left atrial posterior wall electrograms recorded from the esophagus before and 3 months after STAR indicated successful electrical isolation. CONCLUSIONS This is the first report of non-invasive radioablation of the left atrium with demonstration of successful electrical isolation. Although STAR may be safe and effective in delivering ablative energy to the left atrium, further evaluation is warranted regarding effectiveness.
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Affiliation(s)
- Masaaki Shoji
- Department of Cardiovascular Medicine, National Cancer Center Hospital, 5-1-1 Tsukiji Chuo-ku, Tokyo, 104-0045, Japan.
| | - Koji Inaba
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Jun Itami
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Minoru Hamada
- Department of Radiological Technology, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroyuki Okamoto
- Department of Medical Physics, National Cancer Center Hospital, Tokyo, Japan
| | - Takeshi Iwasa
- Department of Cardiovascular Medicine, National Cancer Center Hospital, 5-1-1 Tsukiji Chuo-ku, Tokyo, 104-0045, Japan
| | - Takeshi Ushigusa
- Department of Pathology, National Cancer Center Hospital, Tokyo, Japan
| | - Masayuki Yoshida
- Department of Pathology, National Cancer Center Hospital, Tokyo, Japan
| | - Taka-Aki Matsuyama
- Department of Legal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Takayuki Otsuka
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | | | - Kenzo Hirao
- Division of Cardiovascular Medicine, AOI Universal Hospital, Kanagawa, Japan
| | | | - Pierre Qian
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Paul C Zei
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Boston, MA, USA
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Carbucicchio C, Jereczek-Fossa BA, Andreini D, Catto V, Piperno G, Conte E, Cattani F, Rondi E, Vigorito S, Piccolo C, Bonomi A, Gorini A, Pepa M, Mushtaq S, Fassini G, Moltrasio M, Tundo F, Marvaso G, Veglia F, Orecchia R, Tremoli E, Tondo C. STRA-MI-VT (STereotactic RadioAblation by Multimodal Imaging for Ventricular Tachycardia): rationale and design of an Italian experimental prospective study. J Interv Card Electrophysiol 2021; 61:583-93. [PMID: 32851578 DOI: 10.1007/s10840-020-00855-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 08/17/2020] [Indexed: 12/14/2022]
Abstract
Background Ventricular tachycardia (VT) is a life-threatening condition, which usually implies the need of an implantable cardioverter defibrillator in combination with antiarrhythmic drugs and catheter ablation. Stereotactic body radiotherapy (SBRT) represents a common form of therapy in oncology, which has emerged as a well-tolerated and promising alternative option for the treatment of refractory VT in patients with structural heart disease. Objective In the STRA-MI-VT trial, we will investigate as primary endpoints safety and efficacy of SBRT for the treatment of recurrent VT in patients not eligible for catheter ablation. Secondary aim will be to evaluate SBRT effects on global mortality, changes in heart function, and in the quality of life during follow-up. Methods This is a spontaneous, prospective, experimental (phase Ib/II), open-label study (NCT04066517); 15 patients with structural heart disease and intractable VT will be enrolled within a 2-year period. Advanced multimodal cardiac imaging preceding chest CT-simulation will serve to elaborate the treatment plan on different linear accelerators with target and organs-at-risk definition. SBRT will consist in a single radioablation session of 25 Gy. Follow-up will last up to 12 months. Conclusions We test the hypothesis that SBRT reduces the VT burden in a safe and effective way, leading to an improvement in quality of life and survival. If the results will be favorable, radioablation will turn into a potential alternative option for selected patients with an indication to VT ablation, based on the opportunity to treat ventricular arrhythmogenic substrates in a convenient and less-invasive manner.
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9
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Wenter V, Albert NL, Unterrainer M, Ahmaddy F, Ilhan H, Jellinek A, Knösel T, Bartenstein P, Spitzweg C, Lehner S, Todica A. Clinical impact of follicular oncocytic (Hürthle cell) carcinoma in comparison with corresponding classical follicular thyroid carcinoma. Eur J Nucl Med Mol Imaging 2021; 48:449-60. [PMID: 32683470 DOI: 10.1007/s00259-020-04952-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 07/05/2020] [Indexed: 01/28/2023]
Abstract
PURPOSE There are controversial debates if patients with Hürthle cell carcinoma, also known as oxyphilic or oncocytic cell follicular thyroid carcinoma, have a poorer outcome. In this study, we systematically evaluated the clinical outcome in a large patient cohort following thyroidectomy and initial I-131 radioactive iodine therapy (RIT). METHODS We retrospectively evaluated a total of 378 patients with diagnosed oncocytic follicular Hürthle cell carcinoma (OFTC) (N = 126) or with classical follicular thyroid carcinoma (FTC) (N = 252). Patients received thyroidectomy and complementary I-131 RIT. Clinical data regarding basic demographic characteristics, tumor grade, persistent disease and recurrence during follow-up, and disease-free, disease-specific, and overall survival were collected during follow-up of 6.9 years (interquartile range 3.7; 11.7 years). Univariate and multivariate analyses were used to identify factors associated with disease-related and overall survival. RESULTS Before and after matching for risk factors, recurrence was significantly more frequently diagnosed in OFTC patients during follow-up (17% vs. 8%; p value 0.037). Likewise, OFTC patients presented with a reduced mean disease-free survival of 17.9 years (95% CI 16.0-19.8) vs. 20.1 years (95% CI 19.0-21.1) in FTC patients (p value 0.027). Multivariate analysis revealed OFTC (HR 0.502; 95% CI 0.309-0.816) as the only independent prognostic factor for disease-free survival. Distant metastases of OFTC patients were significantly less iodine-avid (p value 0.014). Mean disease-specific and overall survival did not differ significantly (p value 0.671 and 0.687) during follow-up of median 6.9 years (3.7; 11.7 years). CONCLUSIONS Our study suggests that recurrence is more often seen in OFTC patients. OFTC patients have a poorer prognosis for disease-free survival. Thus, OFTC and FTC behave differently and should be categorized separately. However, patients suffering from OFTC present with the same overall and disease-specific survival at the end of follow-up indifferent to FTC patients after initial RIT.
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10
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Blanck O, Buergy D, Vens M, Eidinger L, Zaman A, Krug D, Rudic B, Boda-Heggemann J, Giordano FA, Boldt LH, Mehrhof F, Budach V, Schweikard A, Olbrich D, König IR, Siebert FA, Vonthein R, Dunst J, Bonnemeier H. Radiosurgery for ventricular tachycardia: preclinical and clinical evidence and study design for a German multi-center multi-platform feasibility trial (RAVENTA). Clin Res Cardiol 2020; 109:1319-1332. [PMID: 32306083 PMCID: PMC7588361 DOI: 10.1007/s00392-020-01650-9] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 04/08/2020] [Indexed: 12/25/2022]
Abstract
Background Single-session high-dose stereotactic radiotherapy (radiosurgery) is a new treatment option for otherwise untreatable patients suffering from refractory ventricular tachycardia (VT). In the initial single-center case studies and feasibility trials, cardiac radiosurgery has led to significant reductions of VT burden with limited toxicities. However, the full safety profile remains largely unknown. Methods/design In this multi-center, multi-platform clinical feasibility trial which we plan is to assess the initial safety profile of radiosurgery for ventricular tachycardia (RAVENTA). High-precision image-guided single-session radiosurgery with 25 Gy will be delivered to the VT substrate determined by high-definition endocardial electrophysiological mapping. The primary endpoint is safety in terms of successful dose delivery without severe treatment-related side effects in the first 30 days after radiosurgery. Secondary endpoints are the assessment of VT burden, reduction of implantable cardioverter defibrillator (ICD) interventions [shock, anti-tachycardia pacing (ATP)], mid-term side effects and quality-of-life (QoL) in the first year after radiosurgery. The planned sample size is 20 patients with the goal of demonstrating safety and feasibility of cardiac radiosurgery in ≥ 70% of the patients. Quality assurance is provided by initial contouring and planning benchmark studies, joint multi-center treatment decisions, sequential patient safety evaluations, interim analyses, independent monitoring, and a dedicated data and safety monitoring board. Discussion RAVENTA will be the first study to provide the initial robust multi-center multi-platform prospective data on the therapeutic value of cardiac radiosurgery for ventricular tachycardia. Trial registration number NCT03867747 (clinicaltrials.gov). Registered March 8, 2019. The study was initiated on November 18th, 2019, and is currently recruiting patients. Graphic abstract ![]()
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Affiliation(s)
- Oliver Blanck
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus 50, 24105, Kiel, Germany.
| | - Daniel Buergy
- Klinik für Strahlentherapie und Radioonkologie, Universitätsmedizin Mannheim, Universität Heidelberg, Medizinische Fakultät Mannheim, Mannheim, Germany
| | - Maren Vens
- Universität zu Lübeck, Zentrum für Klinische Studien, Lübeck, Germany.,Institut für Medizinische Biometrie und Statistik, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Lina Eidinger
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus 50, 24105, Kiel, Germany.,Klinik für Innere Medizin III, Abteilung für Elektrophysiologie und Rhythmologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Adrian Zaman
- Klinik für Innere Medizin III, Abteilung für Elektrophysiologie und Rhythmologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - David Krug
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus 50, 24105, Kiel, Germany
| | - Boris Rudic
- Medizinische Klinik I, Abteilung für Elektrophysiologie und Rhythmologie, Universitätsmedizin Mannheim, Universität Heidelberg, Medizinische Fakultät Mannheim, Mannheim, Germany
| | - Judit Boda-Heggemann
- Klinik für Strahlentherapie und Radioonkologie, Universitätsmedizin Mannheim, Universität Heidelberg, Medizinische Fakultät Mannheim, Mannheim, Germany
| | - Frank A Giordano
- Klinik für Strahlentherapie und Radioonkologie, Universitätsmedizin Mannheim, Universität Heidelberg, Medizinische Fakultät Mannheim, Mannheim, Germany
| | - Leif-Hendrik Boldt
- Medizinische Klinik mit Schwerpunkt Kardiologie (CVK), Abteilung für Elektrophysiologie und Rhythmologie, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Felix Mehrhof
- Klinik für Radioonkologie und Strahlentherapie, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Volker Budach
- Klinik für Radioonkologie und Strahlentherapie, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Achim Schweikard
- Institut für Robotik und Kognitive Systeme, Universität zu Lübeck, Lübeck, Germany
| | - Denise Olbrich
- Universität zu Lübeck, Zentrum für Klinische Studien, Lübeck, Germany
| | - Inke R König
- Institut für Medizinische Biometrie und Statistik, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Frank-Andre Siebert
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus 50, 24105, Kiel, Germany
| | - Reinhard Vonthein
- Institut für Medizinische Biometrie und Statistik, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Jürgen Dunst
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus 50, 24105, Kiel, Germany
| | - Hendrik Bonnemeier
- Klinik für Innere Medizin III, Abteilung für Elektrophysiologie und Rhythmologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
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Abstract
Stereotactic body radiotherapy uses the principle of 3-dimensional localization of a target to deliver a high dose of radiation to a precise location. The aim of this technique is to ablate tissue noninvasively. Because of its high precision and target conformity, it can deliver a high dose of radiation to a specific area in a tissue without significantly affecting nearby tissues. It is being actively studied and even used in therapy for atrial fibrillation and ventricular tachycardia.
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Affiliation(s)
- Marwan M Refaat
- Cardiovascular Fellowship Program, Department of Internal Medicine, Cardiology Division, Cardiac Electrophysiology Section, American University of Beirut Faculty of Medicine and Medical Center (AUBMC), PO Box 11-0236, Riad El-Solh, Beirut 1107 2020, Lebanon.
| | - Patrick Zakka
- Department of Internal Medicine, Emory University Hospital, 550 Peachtree Street Northeast, Atlanta, GA 30308, USA
| | - Bassem Youssef
- Department of Radiation Oncology, American University of Beirut Medical Center, PO Box 11-0236, Riad El-Solh, Beirut 1107 2020, Lebanon
| | - Youssef H Zeidan
- Department of Radiation Oncology, American University of Beirut Medical Center, PO Box 11-0236, Riad El-Solh, Beirut 1107 2020, Lebanon
| | - Fadi Geara
- Department of Radiation Oncology, American University of Beirut Medical Center, PO Box 11-0236, Riad El-Solh, Beirut 1107 2020, Lebanon
| | - Amin Al-Ahmad
- Texas Cardiac Arrhythmia Institute, St David's Medical Center, 919 East 32nd Street, Austin, TX 78705, USA
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12
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Abstract
The focus of this article is on clinical ethics issues in the thyroid disease context. Clinical ethics is a subspecialty of bioethics that deals with bedside ethical dilemmas that specifically involve the provider-patient relationship. Such issues include consent and capacity; weighing therapeutic benefits against risks and side-effects; innovative therapies; end of life care; unintended versus intentional harms to patients or patient populations; and healthcare access. This article will review core ethical principles for practice, as well as the moral and legal requirements of informed consent. It will then discuss the range of unique and universal ethical issues and considerations that present in the management of autoimmune thyroid disease and thyroid cancer.
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Affiliation(s)
- M Sara Rosenthal
- Program for Bioethics, Department of Internal Medicine, University of Kentucky, 740 S. Limestone Street, Suite K-522, Lexington, KY 40506, USA.
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