Motion Management in a Patient With Tracheostomy During Lung Stereotactic Body Radiation Therapy: Breath Hold Is Worth a Try.
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SUBMITTER: Kaestner L
PROVIDER: S-EPMC8850202 | biostudies-literature | 2022 May-Jun
REPOSITORIES: biostudies-literature
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Motion Management in a Patient With Tracheostomy During Lung Stereotactic Body Radiation Therapy: Breath Hold Is Worth a Try.
Kaestner Lena L Abo-Madyan Yasser Y Huber Lena L Spaniol Manon M Siebenlist Kerstin K Sacks Marie-Kristin MK Ehmann Michael M Stieler Florian F Clausen Sven S Lohr Frank F Fleckenstein Jens J Boda-Heggemann Judit J
Advances in radiation oncology 20220115 3
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Project description:Radiotherapy with deep inspiration breath hold (DIBH) reduces doses to the lungs and organs at risk. The stability of breath holding and reproducibility of tumor location are higher during expiration than during inspiration; therefore, we developed an irradiation method combining DIBH and real-time tumor-tracking radiotherapy (RTRT) (DBRT). Nine patients were enrolled in this study. Fiducial markers were placed near tumors using bronchoscopy. Treatment planning computed tomography (CT) was performed thrice during DIBH, assisted by spirometer-based device. Each CT scan was fused using fiducial markers. Gross tumor volume (GTV) was contoured for each dataset and summed to create GTVsum; adding a 5-mm margin around GTVsum generated the planning target volume. The prescribed dose was mainly 42 Gy in four fractions. The treatment plan was created using DIBH CT (DBRT-plan), with a similar treatment plan created for expiratory CT for cases for which DBRT could not be performed (conv-plan). Vx defined as the volume of the lung received x Gy, and the mean lung dose, V20, V10, and V5 were evaluated. DBRT was completed in all patients. Mean dose, V20, and V10 were significantly lower in the DBRT-plan than in the conv-plan (all p = 0.003). Mean rates of decrease for mean dose, V20, and V10 were 14.0%, 27.6%, and 19.1%, respectively. No significant difference was observed in V5. We developed DBRT, a stereotactic body radiation therapy performed with the DIBH technique; it combines a spirometer-based breath-hold support system with an RTRT system. All patients who underwent DBRT completed the procedure without any technical or mechanical complications. This is a promising methodology that may significantly reduce lung doses.
| S-EPMC10825222 | biostudies-literature
Project description:Purpose/objectivesFor lung stereotactic body radiation therapy (SBRT), real-time tumor tracking (RTT) allows for less radiation to normal lung compared to the internal target volume (ITV) method of respiratory motion management. To quantify the advantage of RTT, we examined the difference in radiation pneumonitis risk between these two techniques using a normal tissue complication probability (NTCP) model.Materials/method20 lung SBRT treatment plans using RTT were replanned with the ITV method using respiratory motion information from a 4D-CT image acquired at the original simulation. Risk of symptomatic radiation pneumonitis was calculated for both plans using a previously derived NTCP model. Features available before treatment planning that identified significant increase in NTCP with ITV versus RTT plans were identified.ResultsPrescription dose to the planning target volume (PTV) ranged from 22 to 60 Gy in 1-5 fractions. The median tumor diameter was 3.5 cm (range 2.1-5.5 cm) with a median volume of 14.5 mL (range 3.6-59.9 mL). The median increase in PTV volume from RTT to ITV plans was 17.1 mL (range 3.5-72.4 mL), and the median increase in PTV/lung volume ratio was 0.46% (range 0.13-1.98%). Mean lung dose and percentage dose-volumes were significantly higher in ITV plans at all levels tested. The median NTCP was 5.1% for RTT plans and 8.9% for ITV plans, with a median difference of 1.9% (range 0.4-25.5%, pairwise P < 0.001). Increases in NTCP between plans were best predicted by increases in PTV volume and PTV/lung volume ratio.ConclusionsThe use of RTT decreased the risk of radiation pneumonitis in all plans. However, for most patients the risk reduction was minimal. Differences in plan PTV volume and PTV/lung volume ratio may identify patients who would benefit from RTT technique before completing treatment planning.
| S-EPMC6036380 | biostudies-literature
Project description:This clinical study aimed to evaluate lung cancer patients' ability to perform deep inspiration breath-hold (DIBH) during CT simulation and throughout the treatment course of stereotactic body radiation therapy (SBRT). In addition, target sizes, organ at risk (OAR) sizes, and doses to the respective volumes in filter-free volumetric-modulated arc therapy plans performed under free-breathing (FB) and DIBH conditions were evaluated. Twenty-one patients with peripheral lesions were included, of which 13 were eligible for SBRT. All patients underwent training for breath-hold during CT, and if they complied with the requirements, two CT scans were obtained: CT scan in DIBH and a four-dimensional CT scan in FB. The treatment plans in FB and DIBH were generated, and the dose parameters and volume sizes were compared. The endpoints for evaluation were patient compliance, target dose coverage, and doses to the OARs. This clinical study showed high patient DIBH compliance during both CT simulation and treatment for patients with lung cancer. A significant reduction in target volumes was achieved with SBRT in DIBH, in addition to significantly decreased doses to the heart, chest wall, and lungs. DIBH in SBRT of lung lesions is feasible, and a routine to manage intra-fractional deviation should be established upon implementation.
| S-EPMC9512343 | biostudies-literature
Project description:Background and purposeIn lung stereotactic body radiation therapy (SBRT) using a breath-holding technique, displacement of tumor during breath-holding is rarely considered. This study used four-dimensional (4D) dose calculation with cine computed tomography (CT) to evaluate the impact of unexpected tumor position displacement during breath-holding on the target dose of lung volumetric modulated arc therapy (VMAT)-SBRT.Materials and methodsThis study included 20 cases for which tumor position displacement during end-exhalation breath-holding (range: 0.5-12.6 mm) was evaluated on cine CT. VMAT-SBRT plans (3D dose) were generated using treatment planning CT images (reference CT) acquired during end-exhalation breath-hold. For each plan, the 4D dose was calculated using deformable image registration of the cine CT images and was accumulated onto the reference CT. Dose metrics and the mean biologically effective dose at α/β = 10 (BED10) for the gross tumor volume (GTV) were compared between 3D and 4D doses.ResultsIn the 17 cases where the tumor was within the planning target volume (PTV) during breath-holding, the difference between the 3D and 4D doses was within 3 % for each dose metric. However, in 3 cases where the tumor position during breath-holding included displacement outside the PTV, both the D98% and mean BED10 of the GTV were reduced by 6.9-20.0 % and 2.1-13.8 %, respectively, in 4D doses compared to 3D doses.ConclusionOur study showed that tumor position displacements during breath-holding may lead to substantial tumor dose reduction.
| S-EPMC11772987 | biostudies-literature
Project description:Background and purposeTumor motion and delivery efficiency are two main challenges of lung stereotactic body radiotherapy (SBRT). The present work implemented the deep inspiration breath hold technique (DIBH) with surface guided radiation therapy (SGRT) on closed-bore linacs and investigated the correlation between SGRT data and internal target position.Materials and methodsThirteen lung SBRT patients treated in DIBH using a closed-bore gantry linac and a ring-mounted SGRT system were retrospectively analysed. Visual coaching was used to achieve DIBH with a ± 1 mm threshold window in the anterior-posterior direction. Three kV-CBCTs were added to the treatment workflow and examined offline to verify intra-fraction tumor position. Surface-based DIBH was analysed using SGRT treatment reports and an in-house python script. Data from 73 treatment sessions and 175 kV-CBCTs were studied. Correlations between target and surface positions were studied with Linear Mixed Models.ResultsMedian intra-fraction tumor motion was 0.8 mm (range: 0.7-1.3 mm) in the anterior-posterior direction, 1.2 mm (range: 1-1.7 mm) in the superior-inferior direction, and 1 mm (range: 0.7-1.1 mm) in the left-right direction, with rotations of <1° (range: 0.6°-1.1°) degree in all three directions. Planned target volumes and healthy lung volumes receiving 12.5 Gy and 13.5 Gy were reduced on average by 67% and 54%, respectively.ConclusionsLung SBRT in DIBH with the ring-mounted SGRT system proved reproducible. The surface monitoring provided by SGRT was found to be a reliable surrogate for internal target motion. Moreover, the implementation of DIBH technique helped reduce target volumes and lung doses.
| S-EPMC10213090 | biostudies-literature
Project description:The role of external beam radiation therapy (EBRT) in the management of upper gastrointestinal malignancies is constantly evolving. As radiation therapy techniques improve and are able to deliver more ablative doses of radiotherapy while sparing healthy tissue, radiation can be applied to a wider range of clinical scenarios. Stereotactic body radiation therapy (SBRT) allows a high dose of radiation to be delivered to a highly conformal treatment volume in a short amount of time. Another potential advantage of SBRT is its ability to increase tumor immunogenicity, while also having less of an immunosuppressive effect on the patient, as compared to conventionally fractionated radiation therapy. In so doing, SBRT may potentiate the effects of immune therapy when the two treatments are combined, thus improving therapeutic outcomes. This article provides an overview of the role of SBRT in the management of upper gastrointestinal GI malignancies and the emerging data on immune biomarkers and SBRT, with a focus on pancreatic and liver cancer.
| S-EPMC5874664 | biostudies-literature
Project description:Background and purposeTo investigate a weighted four-dimensional (W-4D) treatment planning strategy based on the greater clinical advantage of the conformal over the intensity-modulated technique in lung stereotactic body radiotherapy (SBRT).Material and methodsTwo planning strategies (individual-phase 4D [IP-4D] and W-4D) were evaluated in eighteen lung SBRT patients. The IP-4D plan can deliver a constant fluence during whole respiratory phases. The W-4D plan's key concept was to escalate (or reduce) fluence using a 4D optimization algorithm when the tumour target was out-of-line (or in-line) with an organ-at-risk. The fluence was converted to a dynamic multi-leaf collimator leaf sequence for deliverable 4D irradiation.ResultsIn all patients, the W-4D plan enabled planning tumour volume conformity comparable to the IP-4D plan. The W-4D plan yielded a significantly lower maximum dose than the IP-4D plan for the spinal cord (-11%; p<0.01), oesophagus (-14%; p<0.01), heart (-22%; p=0.01) and stomach (-23%; p=0.07), and a lower mean dose to liver (-19%; p=0.18) while maintaining the mean dose to lung (-1%; p=0.23).ConclusionsW-4D is a robust, practical planning approach that achieves significant dose sparing relative to non-time-resolved tracking; it may be of greater clinical benefit in radiotherapy than the spatially intensity-modulated 4D approach.
| S-EPMC5201122 | biostudies-literature
Project description:ObjectivesTo evaluate intrafractional fiducial marker position variations during stereotactic body radiotherapy (SBRT) in patients treated for liver metastases in visually guided, voluntary deep inspiration breath-hold (DIBH).Methods10 patients with implanted fiducial markers were studied. Respiratory coaching with visual guidance was used to ensure comfortable voluntary breath-holds for SBRT imaging and delivery. Three DIBH CTs were acquired for treatment planning. Pre- and post-treatment CBCTs were acquired for each of the three treatment fractions. Per-fraction marker position was evaluated on planar 2D kV images acquired during treatment fractions for 4 of the 10 patients.ResultsThe median difference in marker position was 0.3 cm (range, 0.0-0.9 cm) between the three DIBH CTs and 0.3 cm (range, 0.1 to 1.4 cm) between pre- and post-treatment CBCTs. The maximum intrafractional variation in marker position in craniocaudal (CC) direction on planar kV images was 0.7 to 1.3 cm and up to 1.0 cm during a single DIBH.ConclusionDifference in marker position of up to 1.0 cm was observed during a single DIBH despite use of narrow external gating window and visual feedback. Stability examination on pre-treatment DIBH CTs was not sufficient to guarantee per-fraction stability. Evaluation of differences in marker position on pre- and post-treatment CBCT did not always reveal the full magnitude of the intrafractional variation.Advances in knowledgeTo increase treatment accuracy, it is necessary to apply real-time monitoring of the tumour or a reliable internal surrogate when delivering liver SBRT in voluntary DIBH.
| S-EPMC7716004 | biostudies-literature
Project description:BackgroundThe physiological and pathophysiological mechanisms that govern diving, both self-contained underwater breathing apparatus (SCUBA) and breath-hold diving (BH-diving), are in large part well known, even if there are still many unknown aspects, in particular about cell metabolism during BH-diving. The scope of this study was to investigate changes in glycemia, insulinemia, and the catecholamine response to BH-diving, to better understand if the insulin-stimulated glucose uptake mechanism is involved in cellular metabolism in this sport.MethodsTwenty male experienced healthy breath-hold divers were studied. Anthropometric information was obtained. Glycemia, insulinemia, and catecholamine response were investigated before and after the series of BH-diving.ResultsWe found a statistically significant decrease in the blood glucose levels between before and after dives (mean 94.3 ± 11.6 vs. 83.5 ± 12.5 mg/dl) P = 0.001 and a statistically significant increase in blood insulin value (median 4.5 range 3.4/6.4 vs. 7.0 range 4.2/10.2 mcgU/ml) P < 0.0001. Also, we found a statistically significant increase of catecholamine production (median 14.0 range 8/18 vs. 15.5 range 10.0/21.0 μg) P < 0.0001.ConclusionsThe increase in blood insulin during BH-diving associated with the decrease of blood glucose levels could indicate that the upregulating cellular uptake is not caused by activation of the specific glucose transporters. Particular diving-related conditions such as the diving reflex, the intermittent hypoxia/hyperoxia, and the particular environmental condition could play an important role in the mechanism involved in glycemia decrease in BH-diving. Our data confirm that the adaptations to BH-diving are caused by complex mechanisms and involve many peculiar responses still in large part unknown.
| S-EPMC5871611 | biostudies-literature
Project description:PurposeRadiation therapy for tumors subject to breathing-related motion during breath-holds (BHs) has the potential to substantially reduce the irradiated volume. Mechanically assisted and noninvasive ventilation (MANIV) could ensure the target repositioning accuracy during each BH while facilitating treatment feasibility through oxygen supplementation and a perfectly replicated mechanical support. However, there is currently no clinical evidence substantiating the use of MANIV-induced BH for moving tumors. The aim of this work was, therefore, to evaluate the technique's performance under real treatment conditions.Methods and materialsPatients eligible for lung or liver stereotactic body radiation therapy were prospectively included in a single-arm trial. The primary endpoint corresponded to the treatment feasibility with MANIV. Secondary outcomes comprised intrafraction geometric uncertainties extracted from real-time imaging, tolerance to BH, and treatment time.ResultsTreatment was successfully delivered in 92.9% (13/14) of patients: 1 patient with a liver tumor was excluded because of a mechanically induced gastric insufflation displacing the liver cranially by more than 1 cm. In the left-right/anteroposterior/craniocaudal directions, the recalculated safety margins based on intrafraction positional data were 4.6 mm/5.1 mm/5.6 mm and 4.7 mm/7.3 mm/5.9 mm for lung and liver lesions, respectively. Compared with the free-breathing internal target volume and midposition approaches, the average reduction in the planning target volume with MANIV reached -47.2% ± 15.3%, P < .001, and -29.4% ± 19.2%, P = .007, for intrathoracic tumors and -23.3% ± 12.4%, P < .001, and -9.3% ± 15.3%, P = .073, for upper abdominal tumors, respectively. For 1 liver lesion, large caudal drifts of occasionally more than 1 cm were measured. The total slot time was 53.1 ± 10.6 minutes with a BH comfort level of 80.1% ± 10.6%.ConclusionsMANIV enables high treatment feasibility within a nonselected population. Accurate intrafraction tumor repositioning is achieved for lung tumors. Because of occasional intra-BH caudal drifts, pretreatment assessment of BH stability for liver lesions is, however, recommended.
| S-EPMC11327938 | biostudies-literature