Two years’ experience with inspiration breath-hold in liver SBRT

Mast, M.; Kouwenhoven, E.; Roos, Johan H; Geen, S. van; Egmond, J. Van; Santvoort, J. van; Boer, Lonneke de; Florijn, M.; Kalidien, Y.; Nobel, N.; Rovers, L.; Togt, W. van der; Vet, S. De; Zyp, N. van der Voort van; Wenmakers, F.; Wingerden, J. van; Ceha, Heleen M.

doi:10.1016/j.tipsro.2018.04.001

Cited by 16 publications

(21 citation statements)

References 21 publications

(25 reference statements)

Supporting

Mentioning

Contrasting

Order By: Relevance

“…While use of SBRT in clinical practice has more than doubled over the past decade [20,21], its use for tumors of the liver has yet to match that in the lung primarily because of technical challenges [17,22]. Most significantly, movement of the liver due to the physiologic breathing cycle and poor visibility with contemporary on-board imaging make these targeted treatments challenging [16,17,22,23]. The MR-Linear model used in this report of our institutional experience treating primary and secondary liver cancers addressed these technical challenges by offering superior imaging and allowing for real-time tumor tracking.…”

Section: Discussionmentioning

confidence: 99%

“…Combined with a linear accelerator, conformal intensity-modulated radiation therapy plans can be generated while using real-time image guidance to ensure treatment delivery only when the region of interest is in target position. This is important when considering stereotactic treatment to tumors that may change position during respiration, such as those involving the liver [16,17]. Treatment with the MR-Linac system potentially allows for increased target accuracy, tighter margins, increased dose per fraction, and superior dose constraints.…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Real-time Magnetic Resonance-guided Liver Stereotactic Body Radiation Therapy: An Institutional Report Using a Magnetic Resonance-Linac System

Feldman¹,

Modh²,

Glide-Hurst³

et al. 2019

Cureus

View full text Add to dashboard Cite

BackgroundStereotactic body radiation therapy (SBRT) is a proven and effective modality for treatment of hepatic primary and metastatic tumors. However, these lesions are challenging for planning and treatment execution due to natural anatomic changes associated with respiration. Magnetic resonance imaging (MRI) offers superior soft tissue contrast resolution and the ability for real-time image-guided treatment delivery and lesion tracking.ObjectiveTo evaluate the plan quality, treatment delivery, and tumor response of a set of liver SBRT cancer treatments delivered with magnetic resonance (MR)-guided radiotherapy on a MR-linear accelerator (MR-linac).MethodsTreatment data from 29 consecutive patients treated with SBRT were reviewed. All treatments were performed using a step and shoot technique to one or more liver lesions on an MR-linac platform. Patients received 45 to 50 Gy prescribed to at least 95% of the planning target volume (PTV) in five fractions except for two patients who received 27-30 Gy in three fractions. Computed tomography and MRI simulation were performed in the supine position prior to treatment in the free-breathing, end exhalation, and end inhalation breath-hold positions to determine patient tolerability and potential dosimetric advantages of each technique. Immobilization consisted of using anterior and posterior torso MRI receive coils embedded in a medium-sized vacuum cushion. Gating was performed using sagittal cine images acquired at 4 frames/second. Gating boundaries were defined in the three major axes to be 0.3 to 0.5 cm. An overlapping region of interest, defined as the percentage volume allowed outside the boundary for beam-on to occur, was set between 1 and 10%. The contoured target was assigned a 5-mm PTV expansion. Organs at risk constraints adopted by the American Association of Physicists in Medicine Task Group 101 were used during optimization.ResultsTwenty-nine patients, with a total of 34 lesions, successfully completed the prescribed treatment with minimal treatment breaks or delays. Twenty-one patients were treated at end-exhale, and six were treated at end-inhale. Two patients were treated using a free-breathing technique due to poor compliance with breath-hold instructions. The reported mean liver dose was 5.56 Gy (1.39 - 10.43; STD 2.85) and the reported mean liver volume receiving the prescribed threshold dose was 103.1 cm3 (2.9 - 236.6; STD 75.2). Follow-up imaging at one to 12 months post treatment confirmed either stable or decreased size of treated lesions in all but one patient. Toxicities were mild and included nausea/vomiting, abdominal pain and one case of bloody diarrhea. Four patients died due to complications from liver cirrhosis unrelated to radiation effect.ConclusionSBRT treatment using a gated technique on an MR-linac has been successfully demonstrated. Potential benefits of this modality include decreased liver dose leading to decreased toxicities. Further studies to identify the benefits and risks associated with MR-guided SBRT are necessary.

show abstract

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Real-time Magnetic Resonance-guided Liver Stereotactic Body Radiation Therapy: An Institutional Report Using a Magnetic Resonance-Linac System

Feldman¹,

Modh²,

Glide-Hurst³

et al. 2019

Cureus

View full text Add to dashboard Cite

show abstract

“…To investigate whether our breath-hold technique (Active Breathing Coordinator TM , ABC, Elekta, UK) could reduce CTV-PTV margins, we compared the movement of the adrenal glands both in free-breathing, making use of the MidV technique, and in breath-hold. The breath-hold technique we apply was extensively described earlier [10]. Despite the fact that breathing motion is absent during ABC, a variation in tumour position between consecutive breath-holds should be accounted for in the calculation of margins.…”

Section: Methodsmentioning

confidence: 99%

“…Data were used from a cohort of patients with liver metastases treated with SBRT in breath-hold between January 2016 and May 2017 (liver group). In this group of patients with liver metastases we determined for each patient whether ABC or ITV resulted in the smallest margins [10]. The liver group consisted of patients with a 4D-CT and repeat ABC CT-scans of which at least one adrenal gland was visible on both scans.…”

Section: Methodsmentioning

confidence: 99%

“…A way to achieve this is by reducing the movement of the patient's specific breathing cycle [9]. In our department we apply individual CTV-PTV margins for SBRT of liver metastases with use of a breath-hold technique, Active Breathing Control (ABC) [10]. Therefore, it was questioned if this individualised strategy could be adopted for SBRT of adrenal metastases.…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Breath-hold versus mid-ventilation in SBRT of adrenal metastases

Kuijer

Egmond

Kouwenhoven

et al. 2019

Technical Innovations & Patient Support in Radiation Oncolo

Self Cite

View full text Add to dashboard Cite

To improve local control in radiotherapy of adrenal metastases precise dose delivery without increasing toxicity is vital. Decreasing the Clinical Target Volume (CTV)-Planning Target Volume (PTV) margins by reducing breathing movement can achieve this. Few data were published concerning the effect of a breath-hold technique. This study investigates the potential of Active Breathing Control (ABC) to limit adrenal breathing movement and reduce CTV-PTV margins. Methods: We compared adrenal gland movement in free-breathing, making use of the Mid-ventilation (MidV) technique, and with ABC. The coordinates of the adrenal glands obtained on ten phases of a free breathing 4D-CT and on several repeat inspiration ABC CT-scans were measured. Separate coordinates, the random margin component and the margin vector norm were computed and compared between the two techniques. Results: We compared the two techniques in 11 patients (21 adrenal glands) and found the largest movement in the Z-direction, with values of 8.7 ± 4.2 mm for MidV and 2.4 ± 1.5 mm for ABC. In 71% of the cases ABC resulted in a smaller margin component than MidV, although non-significant (p ! 0.4). Conclusion: Movement of the adrenal gland is largest in the Z-direction. The mean difference in the margin vector norm between both techniques was small with large variations over the patient group, the clinical effect of these differences is unknown. Applying an individualised motion management strategy could be beneficial. If a peak-to-peak amplitude above 15 mm in the Z-direction is observed in the MidV scan we advise to examine if a breath-hold technique could reduce margins.

show abstract

Three discipline collaborative radiation therapy (3DCRT) special debate: We should treat all cancer patients with hypofractionation

Green

Nest

Soisson

et al. 2020

J Applied Clin Med Phys

View full text Add to dashboard Cite

Radiation Oncology is a highly multidisciplinary medical specialty, drawing significantly from three scientific disciplinesmedicine, physics, and biology. As a result, discussion of controversies or changes in practice within radiation oncology must involve input from all three disciplines. For this reason, significant effort has been expended recently to foster collaborative multidisciplinary research in radiation oncology, with substantial demonstrated benefit. 1-3 In light of these results, we endeavor here to adopt this "team-science" approach to the traditional debates featured in this journal. This article is part of a series of special debates entitled "Three Discipline Collaborative Radiation Therapy (3DCRT)" in which each debate team will include a radiation oncologist, medical physicist, and radiobiologist. We hope that this format will not only be engaging for the readership but will also foster further collaboration in the science and clinical practice of radiation oncology. 2 | INTRODUCTION Better Physics, just within this 21st century, now enables us to deliver radiation to a target volume with accuracy better than 1 mm. Given this accuracy, why fractionate at all? If we can put dose only on the cancer, and extremely little on critical normal tissue, then surely just give a high single dose to that cancer, and job done. Local tumor control is 100% with minimal toxicity. If only. Two linked issues keep Biology (radiobiology) in the clinical game. First, our ability to identify, localize, and immobilize anatomy and pathology does not yet correspond with this submillimeter accuracy of radiotherapy delivery. Second, even if that imaging resolution is reached it could still not detect occult disease. Consequently, unless the cancer is truly isolated, which it sometimes may be, for example, in organ-confined early-stage prostate cancer, it is always necessary to "degrade" the treatment plan by defining a CTV and PTV into which the radiation delivery is expanded. This inevitably imposes a risk of normaltissue radiotoxicity, therefore we must use fractionation to minimize that risk. Traditionally, that fractionation has been carried out with doses close to 2 Gy per fraction. In fractionation, the Linear-Quadratic (LQ) model describes the relationship between total dose and dose per fraction, for isoeffect. A lower α/β value indicates a steeper relationship. Generally late-reacting normal tissues exhibit lower α/β and early-reacting normal tissues exhibit higher α/β. Malignancies can have lower or higher α/β depending on the tumor type. In some malignancies, notably human prostate, clinical data indeed indicate α/ β as low as 1.5 and thus in prostate cancers, and likewise in earlystage breast cancers, hypofractionation, arbitrarily defined as a dose per fraction> 2.2 Gy, has become standard of care. In early-stage non-small cell lung cancers a higher α/β is seen, similar to early-reacting normal tissue, but these isolated malignancies can still be more effectively controlled with radical hypofractionation wh...

show abstract

Two years’ experience with inspiration breath-hold in liver SBRT

Cited by 16 publications

References 21 publications

Real-time Magnetic Resonance-guided Liver Stereotactic Body Radiation Therapy: An Institutional Report Using a Magnetic Resonance-Linac System

Real-time Magnetic Resonance-guided Liver Stereotactic Body Radiation Therapy: An Institutional Report Using a Magnetic Resonance-Linac System

Breath-hold versus mid-ventilation in SBRT of adrenal metastases

Three discipline collaborative radiation therapy (3DCRT) special debate: We should treat all cancer patients with hypofractionation

Contact Info

Product

Resources

About