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Automatically gated image-guided breath-hold IMRT is a fast, precise, and dosimetrically robust treatment for lung cancer patients

Automatisch gesteuerte, bildgestützte IMRT im Atemanhalt als schnelle, präzise und dosimetrisch stabile Therapie für Patienten mit Bronchialkarzinom

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Abstract

Background

High-dose radiotherapy of lung cancer is challenging. Tumors may move by up to 2 cm in craniocaudal and anteroposterior directions as a function of breathing cycle. Tumor displacement increases with treatment time, which consequentially increases the treatment uncertainty.

Objective

This study analyzed whether automatically gated cone-beam-CT (CBCT)-controlled intensity modulated fast deep inspiration breath hold (DIBH) stereotactic body radiation therapy (SBRT) in flattening filter free (FFF) technique and normofractionated lung DIBH intensity-modulated radiotherapy (IMRT)/volumetric-modulated arc therapy (VMAT) treatments delivered with a flattening filter can be applied with sufficient accuracy within a clinically acceptable timeslot.

Materials and methods

Plans of 34 patients with lung tumors were analyzed. Of these patients, 17 received computer-controlled fast DIBH SBRT with a dose of 60 Gy (5 fractions of 12 Gy or 12 fractions of 5 Gy) in an FFF VMAT technique (FFF-SBRT) every other day and 17 received conventional VMAT with a flattening filter (conv-VMAT) and 2-Gy daily fractional doses (cumulative dose 50–70 Gy).

Results

FFF-SBRT plans required more monitor units (MU) than conv-VMAT plans (2956.6 ± 885.3 MU for 12 Gy/fraction and 1148.7 ± 289.2 MU for 5 Gy/fraction vs. 608.4 ± 157.5 MU for 2 Gy/fraction). Total treatment and net beam-on times were shorter for FFF-SBRT plans than conv-VMAT plans (268.0 ± 74.4 s vs. 330.2 ± 93.6 s and 85.8 ± 25.3 s vs. 117.2 ± 29.6 s, respectively). Total slot time was 13.0 min for FFF-SBRT and 14.0 min for conv-VMAT. All modalities could be delivered accurately despite multiple beam-on/-off cycles and were robust against multiple interruptions.

Conclusion

Automatically gated CBCT-controlled fast DIBH SBRT in VMAT FFF technique and normofractionated lung DIBH VMAT can be applied with a low number of breath-holds in a short timeslot, with excellent dosimetric accuracy. In clinical routine, these approaches combine optimally reduced lung tissue irradiation with maximal delivery precision for patients with small and larger lung tumors.

Zusammenfassung

Hintergrund

Die Hochdosisstrahlentherapie des Bronchialkarzinoms ist eine Herausforderung. Bis zu 2 cm kann sich der Tumor in kraniokaudaler und anteroposteriorer Richtung bewegen – abhängig vom Atemzyklus. Die Tumorverschiebung nimmt mit der Behandlungsdauer zu, was also die Behandlungsunsicherheit vermehrt.

Ziel

In der vorliegenden Studie wurde untersucht, ob die automatisch gesteuerte, Cone-Beam-Computertomographie(CBCT)-kontrollierte, intensitätsmodulierte stereotaktische Strahlentherapie („stereotactic body radiation therapy“, SBRT) im Atemanhalt nach schneller tiefer Inspiration („deep inspiration breath hold“, DIBH) ohne Ausgleichskörper („flattening filter free“, FFF) und die mit einem Ausgleichskörper applizierte normal fraktionierte intensitätsmodulierte DIBH-Strahlentherapie/volumenmodulierte Strahlentherapie mit Rotation des Bestrahlungsarms („volumetric-modulated arc therapy“, VMAT) der Lunge mit ausreichender Genauigkeit innerhalb eines klinisch akzeptablen Zeitfensters angewendet werden können.

Material und Methoden

Die Bestrahlungspläne von 34 Patienten mit Bronchialkarzinomen wurden ausgewertet. Von diesen Patienten erhielten 17 eine computergesteuerte SBRT mit schneller DIBH und einer Dosis von 60 Gy (5 Fraktionen à 12 Gy oder 12 Fraktionen à 5 Gy) in FFF-VMAT-Technik (FFF-SBRT) jeden 2. Tag, und 17 erhielten eine konventionelle VMAT mit Ausgleichskörper (conv-VMAT) und täglichen Teildosen von 2 Gy (kumulative Dosis: 50–70 Gy).

Ergebnisse

Für Pläne mit FFF-SBRT waren mehr Überwachungseinheiten („monitor units“, MU) erforderlich als für Pläne mit con-VMAT (2956,6 ± 885,3 MU für 12 Gy/Fraktion bzw. 1148,7 ± 289,2 MU für 5 Gy/Fraktion vs. 608,4 ± 157,5 MU für 2 Gy/Fraktion). Die Dauer der Gesamttherapie und der Beam-on-Zeit („Strahl ein“) waren für FFF-SBRT-Pläne kürzer als für Pläne mit conv-VMAT (268,0 ± 74,4 s vs. 330,2 ± 93,6 s bzw. 85,8 ± 25,3 s vs. 117,2 ± 29,6 s). Das Gesamtzeitfenster betrug 13,0 min für FFF-SBRT und 14,0 min für conv-VMAT. Alle Therapiemodalitäten konnten genau appliziert werden – trotz mehrerer Beam-on-/-off-Zyklen – und waren bei mehrfachen Unterbrechungen stabil.

Schlussfolgerung

Automatisch gesteuerte CBCT-kontrollierte SBRT mit schneller DIBH in VMAT-FFF-Technik und normal fraktionierte DIBH-Lungen-VMAT können mit wenigen Malen Luftanhalten in einem kurzen Zeitfenster mit ausgezeichneter dosimetrischer Genauigkeit appliziert werden. Im klinischen Alltag wird bei diesen Ansätzen die optimal reduzierte Bestrahlung des Lungengewebes mit maximaler Bestrahlungspräzision für Patienten mit kleinen und größeren Bronchialkarzinomen kombiniert.

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Authors and Affiliations

  1. Department of Radiotherapy and Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1–3, 68167, Mannheim, Germany

    Anna Simeonova-Chergou M.D., Anika Jahnke Dr.sc.hum, Kerstin Siebenlist, Florian Stieler Dr.sc.hum, Sabine Mai M.D., Judit Boda-Heggemann M.D., Ph.D., Frederik Wenz M.D., Frank Lohr M.D. & Lennart Jahnke Dr.rer.nat

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  1. Anna Simeonova-Chergou M.D.
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  2. Anika Jahnke Dr.sc.hum
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  3. Kerstin Siebenlist
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  4. Florian Stieler Dr.sc.hum
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  5. Sabine Mai M.D.
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  6. Judit Boda-Heggemann M.D., Ph.D.
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  7. Frederik Wenz M.D.
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  8. Frank Lohr M.D.
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  9. Lennart Jahnke Dr.rer.nat
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Correspondence to Anna Simeonova-Chergou M.D..

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Conflicts of interest

A. Simeonova-Chergou, A. Jahnke, L. Jahnke, K. Siebenlist, F. Stieler, S. Mai, J. Boda-Heggemann, F.Wenz, and F. Lohr state that there are no conflicts of interest.

All studies on humans described in the present manuscript were carried out with the approval of the responsible ethics committee and in accordance with national law and the Helsinki Declaration of 1975 (in its current, revised form). Informed consent was obtained from all patients included in studies.

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Anna Simeonova-Chergou and Anika Jahnke contributed equally to this publication.

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Simeonova-Chergou, A., Jahnke, A., Siebenlist, K. et al. Automatically gated image-guided breath-hold IMRT is a fast, precise, and dosimetrically robust treatment for lung cancer patients. Strahlenther Onkol 192, 166–173 (2016). https://doi.org/10.1007/s00066-015-0934-z

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