Objective
The purpose of this study was to investigate optimum emission time of deep inspiration breath-hold (DIBH) positron emission tomography–computed tomography (PET–CT).
Methods
We collected 15 ...PET–CT data sets by adding data of every 10 s and acquisition time ranging from 10 s (1 × 10 s acquisition) to 150 s (15 × 10 s acquisition) for both of DIBH mode and free-breathing condition (continuous mode) in phantom study. The coefficient of variation (CV) of radioactivity concentration was compared to determine optimum emission time of PET–CT. We also compared images of DIBH mode and continuous mode to clarify the influence of diaphragmatic movement in clinical setting.
Results
The mean ± SD of CV in DIBH mode was 1236.3 ± 323.1. When compared with the CV at 120 s, the relative error of CV is within 10% at 110 s (0.204), 15% at 100 s (0.212), and 20% at 90 s (0.222), respectively. Optimum emission time greater than 90 s is required to obtain clinically available images in DIBH mode. In the clinical setting, the SUV of the lung base and measurements of uptake show little influence by respiration on DIBH PET–CT.
Conclusions
Optimum emission time of DIBH technique greater than 90 s acquisition is preferable for clinical use.
Comparer la radiothérapie conformationnelle asservie à la respiration et la radiothérapie conformationnelle classique pour l’irradiation des cancers du poumon non à petites cellules et des cancers du ...sein.
Le projet du programme de Soutien aux techniques innovantes coûteuses (Stic) de 2003 était une étude comparative, non randomisée, multicentrique et prospective qui a inclus entre avril 2004 et juin 2008 dans 20 centres français, un total de 634 patients, 401 atteints de cancer du poumon non à petites cellules et 233 de cancer du sein.
L’analyse des résultats définitifs a confirmé la faisabilité et la bonne reproductibilité des différents systèmes de radiothérapie asservie à la respiration. Il a été observé dans le groupe traité par irradiation asservie à la respiration une diminution des paramètres dosimétriques prédictifs d’une toxicité pulmonaire, cardiaque et œsophagienne, notamment pour les cancers du poumon non à petites cellules. Ces bénéfices dosimétriques ont été surtout rapportés avec les techniques de blocage proche de l’inspiration maximum actif Active Breath Control (ABC, Eleckta™) ou volontaire SDX (Dyn’R™) par rapport au système de synchronisation respiratoire (RPM). Pour les cancers du poumon non à petites cellules, ces bénéfices dosimétriques théoriques étaient corrélés avec une diminution significative de la toxicité clinique aiguë et tardive, notamment pulmonaire. Pour les cancers du sein, bien que moins évident compte tenu de la plus faible dose totale, il a été retrouvé une réduction de la dose au cœur diminuant potentiellement le risque de toxicité cardiaque à long terme, particulièrement lors de l’irradiation du sein gauche, et une réduction de la dose délivrée au sein controlatéral.
La radiothérapie asservie à la respiration apparaît essentielle pour réduire le risque de toxicité aiguë et tardive, notamment pulmonaire et cardiaque, lors des irradiations des cancers du poumon non à petites cellules et des cancers mammaires.
To compare respiratory-gated conformal radiotherapy versus conventional conformal radiotherapy for the irradiation of non-small cells lung cancer and breast cancer.
The STIC 2003 project was a comparative, non-randomized, multicenter and prospective study that included in 20 French centers between April 2004 and June 2008, 634 evaluable patients, 401 non-small cells lung cancer and 233 breast cancers.
The final results confirmed the feasibility and good reproducibility of the various respiratory-gated conformal radiotherapy systems regardless of tumour location. The results of this study demonstrated a marked reduction of dosimetric parameters predictive of pulmonary, cardiac and esophageal toxicity, especially for non-small cells lung cancer, as a result of the various respiratory gating techniques. These dosimetric benefits were mainly observed with deep inspiration breath-hold techniques (ABC and SDX), which markedly increased the total lung volume compared to the inspiration-synchronized system based on tidal volume (RPM). For non-small cells lung cancer, these theoretical dosimetric benefits were correlated with a significant reduction in clinically acute and late toxicities, especially the pulmonary. For breast cancer, although less clear due to the lower total dose, there was a decrease in the dose delivered to the heart, potentially reducing the risk of cardiac toxicity in the long-term, especially during the irradiation of the left breast, and a reduction in dose to the contra lateral breast.
Respiratory-gated radiotherapy appears to be essential to reduce the risk of acute and late toxicities, especially for lungs and heart, during irradiation of non-small cells lung cancer and breast cancers.
Évaluer les différentes techniques de gestion du mouvement respiratoire lors de l’irradiation en conditions stéréotaxiques de lésions pulmonaires.
Sept patients atteints d’une ou plusieurs lésions ...pulmonaires primitives ou secondaires de moins de 5cm (11 tumeurs au total) ont eu quatre acquisitions tomodensitométriques : une en respiration libre, deux en blocage inspiratoire profond à l’aide d’un spiromètre, et une en quatre dimensions. À partir de ces quatre acquisitions, cinq planifications ont été réalisées : une planification en respiration libre (méthode de référence), une en blocage inspiratoire profond (à partir des deux acquisitions en blocage inspiratoire profond), et trois planifications à partir de la tomodensitométrie quadridimensionnelle, une en inspiration, une en expiration et une tenant compte de l’ensemble du déplacement tumoral, c’est-à-dire selon la définition du volume cible interne (internal target volume ITV). Les volumes cibles prévisionnels et les doses reçues par les poumons ont été comparés au moyen d’un test Anova (analysis of variance).
Le volume cible prévisionnel moyen était en respiration libre de 82±28 cm3, ce qui était significativement plus grand que dans les autres modalités (p<0,0001). Par rapport au volume cible prévisionnel en respiration libre, celui en tenant compte de l’ensemble du déplacement tumoral était réduit d’un quart (63±31 cm3) et ceux en blocage inspiratoire profond et à partir de la tomodensitométrie quadridimensionnelle, une en inspiration, une en expiration, étaient réduits d’un tiers (de 50 à 54±24 à 26 cm3). Le volume pulmonaire sain était significativement plus grand en blocage inspiratoire profond (en moyenne de 5500±1500 cm3) par rapport aux autres méthodes (en moyenne de 3540 à 3920 cm3) (p<0,0001), soit une augmentation de 40 à 55 % en inspiration profonde. Les volumes de poumons sains recevant au moins 5 et 20Gy (V5 et V20 poumons) étaient significativement plus grands en respiration libre que dans les autres modalités (p<0,0001) ; le blocage inspiratoire profond était la modalité qui permettait d’obtenir les V5 et V20 poumons les plus faibles (réduction d’un tiers par rapport à la respiration libre).
La radiothérapie en blocage inspiratoire profond offre les avantages dosimétriques les plus importants dans le cadre d’irradiation stéréotaxique : petit volume cible prévisionnel et grand volume pulmonaire. Cependant, les patients doivent être capables de tenir des apnées suffisantes. La synchronisation respiratoire permet également de réduire le volume cible prévisionnel, mais son application nécessite souvent l’implantation de fiduciels radio-opaques qui limitent son utilisation. Une tomodensitométrie quadridimensionnelle permet d’avoir un volume cible prévisionnel personnalisé et réduit par rapport à une tomodensitométrie en respiration libre. Le traitement est simple puisqu’en respiration libre.
To evaluate the different respiratory movement management techniques during irradiation of lung tumours.
Seven patients with one or more primary or secondary lung lesions less than 5cm (11 tumours in total) had three computed tomographies (CT): free-breathing, deep-inspiration breath-hold using a spirometer, and 4-dimensional (4D). From these three acquisitions, five treatment plans were performed: free-breathing (reference method), deep-inspiration breath-hold, and three from the 4D CT: two breathing synchronized treatments (inspiration and expiration) and one treatment taking into account all the tumour motions (definition of the internal target volume ITV). Planning target volume (PTV) size and dose delivered to the lungs were compared.
Mean PTV with the free-breathing modality was 83±28cm3, which was significantly greater than any of the other techniques (P<0.0001). Compared to the free-breathing PTV, PTV defined with the ITV was reduced by one quarter (63±31cm3), and PTV with the deep-inspiration breath-hold, breathing synchronized inspiration and breathing synchronized expiration techniques were reduced by one third (50 to 54±24 to 26cm3). Deep-inspiration led to significantly increase the healthy lung volume compared to other methods (mean volume of 5500±1500cm3 versus 3540 to 3920cm3, respectively, P<0.0001). The volume of healthy lungs receiving at least 5 and 20Gy (V5 and V5) were significantly higher with the free-breathing method than any of the other methods (P<0.0001). The deep-inspiration breath-hold modality led to the lowest lung V5 and V20.
Deep-inspiration breath-hold technique provides the most significant dosimetric advantages: small PTV and large lung volume. However, patients must be able to hold 20seconds of apnea. Respiratory gating also reduces the PTV, but its application often requires the implantation of fiducial, which limit its use. A 4-dimensional CT allows for a personalized and reduced PTV compared to free-breathing CT.
Évaluation de la radiothérapie conformationnelle en inspiration profonde bloquée de type involved-node chez des patients atteints de maladie de Hodgkin localisée sus-diaphragmatiques.
Les patients ...atteints de maladie de Hodgkin localisées sus-diaphragmatiques et irradiés en inspiration profonde bloquée dans notre institution ont été rétrospectivement revus. Tous ont reçu une chimiothérapie avant la radiothérapie. Les volumes traités ont été déterminés selon le concept de la radiothérapie involved-node. La radiothérapie en inspiration profonde bloquée a été réalisée grâce un spiromètre dédié.
Vingt-sept patients atteints de maladie de Hodgkin, 17 de stades I–IIA et dix de stades I–IIB (dont une réfractaire après une première ligne de chimiothérapie), ont été traités de novembre 2004 à octobre 2010. L’âge médian était 27ans (extrêmes : 16–54). À part trois patients, tous ont reçu de trois à six cycles d’une chimiothérapie associant l’adriamycine, la bléomycine, la vinblastine et la dacarbazine. La dose médiane prescrite était 30,6Gy (extrêmes : 20–40). Les doses reçues par le cœur, les coronaires et les poumons étaient satisfaisantes. Le suivi était en médiane de 38 mois (extrêmes : 7–70), la survie sans progression à trois ans et la survie globale à trois ans étaient respectivement de 96 % (intervalle de confiance à 95 % : 79–99 %) et de 95 % (intervalle de confiance à 95 % : 75–99 %). Il y a eu une rechute : une récidive locale est survenue en plein champ d’irradiation, dans la tumeur médiastinale. Il n’y a eu qu’un cas de toxicité de grade 3 : une pneumopathie régressive sous corticothérapie.
L’irradiation involved-node, optimisée grâce à la technique en inspiration profonde bloquée, est efficace et peu toxique. Le suivi à long terme doit se poursuivre, notamment pour évaluer la toxicité cardiaque et coronarienne.
To assess the clinical outcome of the involved-node radiotherapy (INRT) concept with the use of deep-inspiration breath-hold (DIBH) technique in patients with localized supra-diaphragmatic Hodgkin lymphoma.
All were patients with stage I–II Hodgkin lymphoma and they were treated with chemotherapy prior to irradiation. Radiation treatments were delivered using the involved-node radiotherapy concept according to the European Organization for Research and Treatment of Cancer Guidelines and a spirometer dedicated to DIBH radiotherapy was used for every patient.
Twenty-seven patients with Hodgkin lymphoma (26 patients with primary Hodgkin lymphoma, one with refractory disease), treated from November 2004 to October 2010, were retrospectively analysed. The median age was 27 years (range 16 to 54). Seventeen (63%) patients had stage I–IIA and 10 (37%) had stage I–IIB disease. All patients received two to six cycles of adriamycin, bleomycin, vinblastine and dacarbazine. The median radiation dose to patients was 30,6Gy (range: 19,8–40). Protection of various organs at risk was satisfactory. Median follow-up, 3-year progression-free and 3-year overall survival were 38 months (range: 7–70), 96% (95%CI: 79–99%) and 95% (95%CI: 75–99%), respectively. Recurrence occurred in one patient (mediastinal in-field relapse). There was one grade 3 acute toxicity (transient pneumonitis).
Our results suggest that patients with localized Hodgkin lymphoma can be safely and efficiently treated using deep-inspiration breath technique and the involved-node radiotherapy concept. Longer follow-up is needed to assess late toxicity, especially for the heart and the coronary arteries.
We propose a novel method to detect the current state of the quasi-periodic system from image sequences which in turn will enable us to synchronize/gate the image sequences to obtain images of the ...organ system at similar configurations. The method uses the cumulated phase shift in the spectral domain of successive image frames as a measure of the net motion of objects in the scene. The proposed method is applicable to 2D and 3D time varying sequences and is not specific to the imaging modality. We demonstrate its effectiveness on X-Ray Angiographic and Cardiac and Liver Ultrasound sequences. Knowledge of the current (cardiac or respiratory) phase of the system, opens up the possibility for a purely image based cardiac and respiratory gating scheme for interventional and radiotherapy procedures.
Tumor motion due to respiration during radiation therapy for non-small cell lung cancer is a significant problem. This article reports on two techniques used to control tumor motion: respiratory ...gating and the deep inspiration breath hold technique. This technique was implemented in 40 patients without significant difficulties and there are encouraging clinical outcomes.
To investigate the dosimetric effect of intended beam interruption during volumetric modulated arc therapy (VMAT) with flattening filter free (FFF) beam for exploring the possibility of deep ...inspiration breath hold stereotactic body radiation therapy (SBRT). A total of ten SBRT plans with 6 and 10 MV FFF beams were retrospectively selected. All plans consisted of four partial arcs, except one plan with six partial arcs. We delivered the plans using a Varian Truebeam™ with three different scenarios; without interruption (0int), with one intentional interruption (1int), or with two intentional interruptions (2int), per each partial arc. The treatment log files were exported from the treatment console, and the variations in delivered MU were evaluated at the beam interruption angles. The dose distributions were also measured using a 3D cylindrical diode array detector, ArcCHECK™. The 2D global gamma evaluations were performed, compared to the planned dose distribution, with 3%/3 and 4%/2 mm passing criterion. The dose difference (DD) was also determined between uninterrupted and interrupted data with 3, 2, 1, and 0.5% of global maximum dose. The interruption caused a total increase of 0.14 ± 0.05% and 0.25 ± 0.08% of the total planned MU, ranging from 1746 to 3261 MU, at the interrupted angles in 1int and 2int, respectively. All global gamma passing rates satisfied our clinical threshold of 90%, and the differences of passing rates were less than 0.3% on average with both criterions. All measured 1int and 2int data were within 3% DD from 0int measured data. For 6 MV FFF beams, the average passing rate with 2, 1, and 0.5% DD were 99.9 ± 0.2%, 92.3 ± 12.0%, and 81.9 ± 24.9%, respectively, between 0int and 1int, and 99.8 ± 0.4%, 92.1%12.4%, and 80.7 ± 26.5%, respectively, between 0int and 2int. For 10 MV FFF beams, the average passing rate with 2, 1, and 0.5% DD were 100.0 ± 0.2%, 95.4 ± 9.4% and 87.0 ± 19.8%, respectively, between 0int and 1int, and 99.9 ± 0.3%, 95.4 ± 9.7%, and 87.2 ± 21.3% between 0int and 2int. The dosimetric impact of beam interruption was investigated with small field and high dose rate FFF-VMAT SBRT plans. The delivered dose distributions with up to 12 interruptions per plan were still clinically acceptable. Only minimal changes were observed in Gamma, DD, and log file analysis.
Aim: To investigate the influence of deep inspiration breath-hold on the oxygen tension of
in-vivo tumours measured using an Eppendorf pO
2histograph.
Materials and methods: Patients with accessible ...primary or metastatic tumours ≥2
cm diameter were entered into a protocol measuring tumour oxygenation with an Eppendorf pO
2histograph during normal breathing (NB) and deep inspiration breath-hold (DIBH). Change in oxygen tension was assessed using the Wilcoxon Signed Ranks test.
Results: Thirty patients were entered in to this protocol. The median maximum tumour dimension was 4
cm. The median of the median pO
2of these tumours was 18
mmHg. Tumours were assessed during NB and DIBH. Oxygen tension measurements along 1–3 pairs of tracks per tumour (median of 2) were obtained. The median number of measurements per track was 30 for NB and 29 for DIBH (range 17–59). In six tumours, the values during NB were significantly higher than during DIBH, whereas, for six other tumours, the relationship was the opposite; for the remaining 18 patients, no significant difference was observed.
Conclusion: These data show heterogeneity of tumour oxygenation seen with
in-situ tumours both at baseline and as a result of DIBH. No systematic change in the Eppendorf pO
2measurements was seen as a result of DIBH; however, the individual tumour responses to DIBH varied dramatically.
Nine cases of primary hepatocellular carcinoma were treated with 3D-conformal radiation therapy using computerized planning system. This technique permits the precise delivery of a high dose of ...radiation to the target while sparing most of the normal liver tissue. In order to decrease the effect of organ movement related to respiration, periodical irradiation was combined with the deep inspiration breath-hold technique. The radiation dose was equivalent to conventional radiation with a total dose of 50-70 Gy with 2 Gy, 5 times a week. Irradiation was given in 1-10 fractions which encompassed the target with 90 per cent isodose line. The patients tolerated the treatment procedure well without any complications inherent to the technique. The tumors were decreased in size, the pain symptom and abdominal discomfort were relieved for 3-20 months. This technique is an effective and safe treatment for palliation in hepatocellular carcinoma especially in locally advanced stages with large or multiple lesions. However, long term follow-up should be done to evaluate the late radiation effect and clinical outcome.
PDF
