Dosimetric consequences of breath-hold respiration in conformal radiotherapy of esophageal cancer

doi:10.1016/S1120-1797(06)80047-5

Physica Medica

Volume 22, Issue 4, October–December 2006, Pages 119-126

https://doi.org/10.1016/S1120-1797(06)80047-5 Get rights and content

Abstract

The objective of this paper is to study the dosimetric impact of respiratory gated radiotherapy in locally advanced esophageal carcinomaand to define the optimal respiratory phase for this treatment.

The study included 8 consecutive patients with squamous-cell carcinoma (SCC) or histologically proved adenocarcinoma, for both at least T3–T4 NX or TX N1 M0 stage. Informed consent was obtained before beginning the study. Three spiral scans were performed in breath-hold respiration: one acquisition in end expiration (EBH), one in end inspiration (IBH) and one in deep inspiration breathhold (DIBH); and one acquisition was performed in Free Breathing (FB). A 3 mm-margin was defined as Internal Target Volume (ITV) on FB CT-scan. No ITV was applied on EBH, IBH and DIBH CT-scan. Target volumes were analyzed and we performed dosimetric comparisons on DVH data of each CT-scan for PTV and Organs at Risk (OAR) (Conformity Index, V_dose, D_mean, Equivalent Uniform Dose).

DIBH and IBH correlated with a 32% (p=0.77) and 20% (p=0.52) decrease in lung V₂₀ respectively as compared to FB (13.5%and 15.6% respectively versus 19.9%). DIBH and IBH correlated with a 25% (p=0.25) and 17% (p=0.39) decrease in cardiac V₄₀ respectively, as compared with FB (16.9% and 18.9% respectively versus 22.7%). For spinal cord irradiation, the minimum dose was obtained in IBH (36.5 Gy).

Conformal radiotherapy with respiratory gating for esophageal cancer decreases the irradiated dose to OAR. We suggest that DIBH technique should be used when irradiation is performed using the spirometric system. In the Tidal Volume, the inspiration phase is the most favourable and should be chosen for irradiation with a free breathing gating system.

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Dosimetric Benefits of Midposition Compared With Internal Target Volume Strategy for Esophageal Cancer Radiation Therapy
2019, International Journal of Radiation Oncology Biology Physics
Citation Excerpt :
In clinical practice, a more efficient approach to generate the region-specific PTV is needed. An alternative to the MidP strategy, the use of a breath-hold technique, especially inhalation breath hold, could also be appealing to use as a motion-management strategy in esophageal cancer RT because of the reduced lung dose compared with free-breathing treatment.46,47 The reductions in mean dose to the lung were <3 Gy for a total dose of 50 to 60 Gy.
Both midposition (MidP) and internal target volume (ITV) strategies can take the respiration-induced target motion into account. This study aimed to compare these 2 strategies in terms of clinical target volume (CTV) coverage and dose to organs at risk (OARs) for esophageal cancer radiation therapy (RT).
Fifteen patients with esophageal cancer were included retrospectively for neoadjuvant RT planning. Per patient, a 10-phase, 4-dimensional (4D) computed tomography (CT) scan (4D-CT) was acquired with CTV and OARs delineated on the 20% phase. The MidP-CT scan was reconstructed based on deformable image registration between the 20% phase and the other 9 phases; thereby, the CTV and OARs delineations were propagated and an ITV was constructed. Both MidP and ITV strategies were used for treatment planning, yielding the planned dose. Next, these plans were applied to the 10-phase 4D-CT to calculate the dose distribution for each phase of the 4D-CT. On the basis of the deformable image registration, these calculated dose distributions were warped and averaged to yield the accumulated 4D dose. Subsequently, we compared, in terms of CTV coverage and dose to OARs, the planned dose with the accumulated 4D dose and the MidP strategy with the ITV strategy.
The differences between the planned dose and the accumulated 4D dose were limited and clinically irrelevant. In 14 patients, both MidP and ITV strategies showed V_95% > 98% for the CTV. Compared with the ITV strategy, the MidP strategy showed a significant reduction of approximately 10% in the dose-volume histogram parameters for the lungs, heart, and liver (P < .001, Wilcoxon signed-rank test).
Compared with the ITV strategy, the MidP strategy in treatment planning can lead to a reduction of approximately 10% in the dose to OARs, with an adequate CTV coverage for esophageal cancer RT.
Quantification of respiration-induced esophageal tumor motion using fiducial markers and four-dimensional computed tomography
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If the respiration-induced tumor motion observed in the pretreatment 4DCT is found not representative for that during the treatment course and meanwhile 4DCBCTs are available for tumor-/marker-based setup verification, using the mid-ventilation approach as done in RT for lung cancer would be a possibility [30]. Otherwise, an active breathing control or a breath-holding technique could be applied as [6,7] did. These will be investigated in the follow-up studies.
Respiration-induced tumor motion is an important geometrical uncertainty in esophageal cancer radiation therapy. The aim of this study was to quantify this motion using fiducial markers and four-dimensional computed tomography (4DCT).
Twenty esophageal cancer patients underwent endoscopy-guided marker implantation in the tumor volume and 4DCT acquisition. The 4DCT data were sorted into 10 breathing phases and the end-of-inhalation phase was selected as reference. We quantified for each visible marker (n = 60) the motion in each phase and derived the peak-to-peak motion magnitude throughout the breathing cycle. The motion was quantified and analyzed for four different regions and in three orthogonal directions.
The median(interquartile range) of the peak-to-peak magnitudes of the respiration-induced marker motion (left–right/anterior–posterior/cranial–caudal) was 1.5(0.5)/1.6(0.5)/2.9(1.4) mm for the proximal esophagus (n = 6), 1.5(1.4)/1.4(1.3)/3.7(2.6) mm for the middle esophagus (n = 12), 2.6(1.3)/3.3(1.8)/5.4(2.9) mm for the distal esophagus (n = 25), and 3.7(2.1)/5.3(1.8)/8.2(3.1) mm for the proximal stomach (n = 17).
The variations in the results between the three directions, four regions, and patients suggest the need of individualized region-dependent anisotropic internal margins. Therefore, we recommend using markers with 4DCT to patient-specifically adapt the internal target volume (ITV). Without 4DCT, 3DCTs at the end-of-inhalation and end-of-exhalation phases could be alternatively applied for ITV individualization.
Deep Inspiration Breath Hold - Based Radiation Therapy: A Clinical Review
2016, International Journal of Radiation Oncology Biology Physics
Citation Excerpt :
Clinical evidence is, however, not yet available. Dosimetric advantages with reduced lung and cardiac dose have been also demonstrated for thoracic esophageal cancer (183, 184). The noninvasive ablation of kidney tumors has become an intriguing concept, now that evidence regarding the abscopal effects of large radiation doses is mounting (185).
Several recent developments in linear accelerator–based radiation therapy (RT) such as fast multileaf collimators, accelerated intensity modulation paradigms like volumeric modulated arc therapy and flattening filter-free (FFF) high-dose-rate therapy have dramatically shortened the duration of treatment fractions. Deliverable photon dose distributions have approached physical complexity limits as a consequence of precise dose calculation algorithms and online 3-dimensional image guided patient positioning (image guided RT). Simultaneously, beam quality and treatment speed have continuously been improved in particle beam therapy, especially for scanned particle beams. Applying complex treatment plans with steep dose gradients requires strategies to mitigate and compensate for motion effects in general, particularly breathing motion. Intrafractional breathing-related motion results in uncertainties in dose delivery and thus in target coverage. As a consequence, generous margins have been used, which, in turn, increases exposure to organs at risk. Particle therapy, particularly with scanned beams, poses additional problems such as interplay effects and range uncertainties. Among advanced strategies to compensate breathing motion such as beam gating and tracking, deep inspiration breath hold (DIBH) gating is particularly advantageous in several respects, not only for hypofractionated, high single-dose stereotactic body RT of lung, liver, and upper abdominal lesions but also for normofractionated treatment of thoracic tumors such as lung cancer, mediastinal lymphomas, and breast cancer. This review provides an in-depth discussion of the rationale and technical implementation of DIBH gating for hypofractionated and normofractionated RT of intrathoracic and upper abdominal tumors in photon and proton RT.
Respiratory Motion in Positron Emission Tomography/Computed Tomography: A Review
2008, Seminars in Nuclear Medicine
Citation Excerpt :
CT acquisition during breath-holding (BH) is a standard technique in radiology that can eliminate respiratory motion artifacts in CT images. This technique has been investigated most notably in connection with BH radiotherapy41-43 and to reduce the irradiated heart volume in breast cancer patients.44 Pan and coworkers2 introduced a novel method, 4-dimensional CT imaging, or 4D-CT, as an alternate method that can provide images of all phases of the breathing cycle.
The development of positron emission tomography/computed tomography (PET/CT) scanners has allowed not only straightforward but also synergistic fusion of anatomical and functional information. Combined PET/CT imaging yields an increased sensitivity and specificity beyond that which either of the 2 modalities possesses separately and therefore provides improved diagnostic accuracy. Because attenuation correction in PET is performed with the use of CT images, with CT used in the localization of disease, accurate spatial registration of PET and CT image sets is required. Correcting for the spatial mismatch caused by respiratory motion represents a particular challenge for the requisite registration accuracy as a result of differences in temporal resolution between the 2 modalities. This review provides a brief summary of the materials, methods, and results involved in multiple investigations of the correction for respiratory motion in PET/CT imaging of the thorax, with the goal of improving image quality and quantitation. Although some schemes use respiratory-phase data selection to exclude motion artifacts, others have adopted sophisticated software techniques. The various image artifacts associated with breathing motion are also described.
Technical Aspects of Positron Emission Tomography/Computed Tomography Fusion Planning
2008, Seminars in Nuclear Medicine
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The authors compared the dose volume histograms for the PTV and the organs at risk for each conformal radiation plan. The found that the radiation dose to the heart and lungs was less with RGRT plans developed with deep inspiration breath-hold and end-inspiration breath hold in comparison to plans derived with free-breathing CT.30 The 4D imaging is a sequential set of 3D imaging studies broken into groupings by some external signal, called the surrogate signal.
Emerging technologies in radiation therapy computers and delivery systems allow surgically precise conformal radiation treatment that was not possible with previous generations of equipment. The newest treatment systems can compensate for tumor target motion as well as shape dose distributions to conform precisely to delineated target volumes. These sophisticated technologies now drive the development of imaging modalities able to generate equally high-resolution and lesion-specific roadmaps that are the foundation of these highly accurate radiation plans. Positron emission tomography/computed tomography (PET/CT) is currently becoming a routine imaging tool for radiation oncology because of its combined benefits of positron imaging and high-resolution anatomic display. The improved staging and lesion delineation provided by PET, combined with the 3D anatomic display provided by CT, now allows better treatment stratification and more precise targeting. Additionally, respiratory-gated 4D CT and 4D PET/CT have been used in the simulation process for respiratory-gated radiation therapy. Successful integration of PET/CT into the radiation therapy planning process requires an understanding of how therapy plans are derived and the process by which the patient receives therapy, because these dictate the method of image acquisition. The radiation oncologists, too, must understand the technology of positron imaging to adapt these functional images based on intensities rather than pixels to their targeting process. Modifications to the PET/CT scanner and room are necessary to image the patient in the reproducible position required for treatment planning. Although the impact of these efforts on patient outcome has yet to be determined, the benefit of better treatment choice, due to improved staging, and more precise targeting with less normal tissue exposure resulting in improved quality of life will likely promote PET/CT to the gold-standard for targeted therapies.
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Original paperDosimetric consequences of breath-hold respiration in conformal radiotherapy of esophageal cancer

Abstract

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Radiother Oncol

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Original paper
Dosimetric consequences of breath-hold respiration in conformal radiotherapy of esophageal cancer