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Maraldo M, Rechner L, Josipovic M, Petersen P, Specht L, Aznar M. PO-0733: PTV margins for mediastinal lymphoma in deep inspiration breath-hold using daily image guidance. Radiother Oncol 2018. [DOI: 10.1016/s0167-8140(18)31043-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Damkjær S, Hoffmann L, Møller D, Petersen J, Josipovic M, Persson G, Munck af Rosenschöld P, Poulsen P. EP-1812: Proton pencil beam scanning with motion emulated as spot shifts: dose reconstruction for lung cancer. Radiother Oncol 2018. [DOI: 10.1016/s0167-8140(18)32121-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Lundgaard AY, Hjalgrim LL, Rechner LA, Josipovic M, Joergensen M, Aznar MC, Berthelsen AK, Borgwardt L, Johansen C, Loft A, Safwat A, Vaalavirta L, Specht L, Maraldo MV. TEDDI: radiotherapy delivery in deep inspiration for pediatric patients - a NOPHO feasibility study. Radiat Oncol 2018; 13:56. [PMID: 29587881 PMCID: PMC5872576 DOI: 10.1186/s13014-018-1003-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 03/16/2018] [Indexed: 01/30/2023] Open
Abstract
Background Radiotherapy (RT) delivered in deep inspiration breath-hold (DIBH) is a simple technique, in which changes in patient anatomy can significantly reduce the irradiation of the organs at risk (OARs) surrounding the treatment target. DIBH is routinely used in the treatment of some adult patients to diminish the risk of late effects; however, no formalized studies have addressed the potential benefit of DIBH in children. Methods/Design TEDDI is a multicenter, non-randomized, feasibility study. The study investigates the dosimetric benefit of RT delivered in DIBH compared to free breathing (FB) in pediatric patients. Also, the study aims to establish the compliance to DIBH and to determine the accuracy and reproducibility in a pediatric setting. Pediatric patients (aged 5–17 years) with a tumor in the mediastinum or upper abdomen with the possible need of RT will be included in the study. Written informed consent is obligatory. Prior to any treatment, patients will undergo a DIBH training session followed by a diagnostic PET/CT- or CT-staging scan in both DIBH and FB. If the patient proceeds to RT, a RT planning CT scan will be performed in both DIBH and FB and two separate treatment plans will be calculated. The superior treatment plan, i.e. equal target coverage and lowest overall dose to the OARs, will be chosen for treatment. Patient comfort will be assessed daily by questionnaires and by adherence to the respiratory management procedure. Discussion RT in DIBH is expected to diminish irradiation of the OARs surrounding the treatment target and thereby reduce the risk of late effects in childhood cancer survivors. Trial registration The Danish Ethical Committee (H-16035870, approved November 24th 2016, prospectively registered). The Danish Data Protection Agency (2012–58-0004, approved January 1st 2017, prospectively registered). Registered at clinicaltrials.gov (NCT03315546, October 20th 2017, retrospectively registered).
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Aznar MC, Warren S, Hoogeman M, Josipovic M. The impact of technology on the changing practice of lung SBRT. Phys Med 2018; 47:129-138. [PMID: 29331227 PMCID: PMC5883320 DOI: 10.1016/j.ejmp.2017.12.020] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 11/20/2017] [Accepted: 12/23/2017] [Indexed: 02/09/2023] Open
Abstract
Stereotactic body radiotherapy (SBRT) for lung tumours has been gaining wide acceptance in lung cancer. Here, we review the technological evolution of SBRT delivery in lung cancer, from the first treatments using the stereotactic body frame in the 1990's to modern developments in image guidance and motion management. Finally, we discuss the impact of current technological approaches on the requirements for quality assurance as well as future technological developments.
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Gorgisyan J, Munck af Rosenschold P, Perrin R, Persson GF, Josipovic M, Belosi MF, Engelholm SA, Weber DC, Lomax AJ. Feasibility of Pencil Beam Scanned Intensity Modulated Proton Therapy in Breath-hold for Locally Advanced Non-Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2017; 99:1121-1128. [DOI: 10.1016/j.ijrobp.2017.08.023] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 07/13/2017] [Accepted: 08/16/2017] [Indexed: 12/25/2022]
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Persson G, Aznar M, Rydhög J, Mortensen S, Nygaard L, Pøhl M, Langer S, Specht L, Josipovic M. Deep Inspiration Breath Hold Compliance in Radiation Therapy for Locally Advanced Lung Cancer. Int J Radiat Oncol Biol Phys 2017. [DOI: 10.1016/j.ijrobp.2017.06.1775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Gorgisyan J, Perrin R, Lomax AJ, Persson GF, Josipovic M, Engelholm SA, Weber DC, Munck af Rosenschold P. Impact of beam angle choice on pencil beam scanning breath-hold proton therapy for lung lesions. Acta Oncol 2017; 56:853-859. [PMID: 28464744 DOI: 10.1080/0284186x.2017.1287950] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The breath-hold technique inter alia has been suggested to mitigate the detrimental effect of motion on pencil beam scanned (PBS) proton therapy dose distributions. The aim of this study was to evaluate the robustness of incident proton beam angles to day-to-day anatomical variations in breath-hold. MATERIALS AND METHODS Single field PBS plans at five degrees increments in the transversal plane were made and water-equivalent path lengths (WEPLs) were derived on the planning breath-hold CT (BHCT) for 30 patients diagnosed with locally-advanced non-small cell lung cancer (NSCLC), early stage NSCLC or lung metastasis. Our treatment planning system was subsequently used to recalculate the plans and derive WEPL on a BHCT scan acquired at the end of the treatment. Changes to the V95%, D95 and mean target dose were evaluated. RESULTS The difference in WEPL as a function of the beam angle was highly patient specific, with a median of 3.3 mm (range: 0.0-41.1 mm). Slightly larger WEPL differences were located around the lateral or lateral anterior/posterior beam angles. Linear models revealed that changes in dose were associated to the changes in WEPL and the tumor baseline shift (p < 0.05). CONCLUSIONS WEPL changes and tumor baseline shift can serve as reasonable surrogates for dosimetric uncertainty of the target coverage and are well-suited for routine evaluation of plan robustness. The two lateral beam angles are not recommended to use for PBS proton therapy of lung cancer patients treated in breath-hold, due to the poor robustness for several of the patients evaluated.
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Josipovic M, Persson G, Bangsgaard J, Specht L, Aznar M. EP-1548: Dose to risk organs in deep inspiration breath hold non-coplanar VMAT for lung cancer radiotherapy. Radiother Oncol 2017. [DOI: 10.1016/s0167-8140(17)31983-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Josipovic M, Persson GF, Bangsgaard JP, Specht L, Aznar MC. Deep inspiration breath-hold radiotherapy for lung cancer: impact on image quality and registration uncertainty in cone beam CT image guidance. Br J Radiol 2016; 89:20160544. [PMID: 27706950 PMCID: PMC5604920 DOI: 10.1259/bjr.20160544] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 08/20/2016] [Accepted: 10/03/2016] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE We investigated the impact of deep inspiration breath-hold (DIBH) and tumour baseline shifts on image quality and registration uncertainty in image-guided DIBH radiotherapy (RT) for locally advanced lung cancer. METHODS Patients treated with daily cone beam CT (CBCT)-guided free-breathing (FB) RT had an additional CBCT in DIBH at three fractions. These CBCT scans were offline rigidly registered (on tumour) to FB and DIBH CT scans acquired at planning. All registrations were repeated to evaluate the intraobserver uncertainty. CBCT scans were scored on degree of streak artefacts and visualization of tumour and anatomical structures. We examined the impact of tumour baseline shift between consecutive DIBHs on CBCT image quality. RESULTS CBCT scans from 15 patients were analysed. Intraobserver image registration uncertainty was approximately 2 mm in both FB and DIBH, except for the craniocaudal direction in FB, where it was >3 mm. On the 31st fraction, the intraobserver uncertainty increased compared with the second fraction. This increase was more pronounced in FB. Image quality scores improved in DIBH compared with FB for all parameters in all patients. Simulated tumour baseline shifts ≤2 mm did not affect the CBCT image quality considerably. CONCLUSION DIBH CBCT improved image quality and reduced registration uncertainty in the craniocaudal direction in image-guided RT of locally advanced lung cancer. Baseline shifts ≤2 mm in DIBH during CBCT acquisition did not affect image quality. Advances in knowledge: DIBH RT has dosimetric advantages over FB; this work demonstrates an additional benefit of DIBH in terms of registration accuracy because of improved image quality.
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Persson GF, Scherman Rydhög J, Josipovic M, Maraldo MV, Nygård L, Costa J, Berthelsen AK, Specht L, Aznar MC. Deep inspiration breath-hold volumetric modulated arc radiotherapy decreases dose to mediastinal structures in locally advanced lung cancer. Acta Oncol 2016; 55:1053-6. [PMID: 26935017 DOI: 10.3109/0284186x.2016.1142115] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Revised: 01/05/2016] [Accepted: 01/10/2016] [Indexed: 12/25/2022]
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Miocinovic J, Miloradovic Z, Josipovic M, Nedeljkovic A, Radovanovic M, Pudja P. Rheological and textural properties of goat and cow milk set type yoghurts. Int Dairy J 2016. [DOI: 10.1016/j.idairyj.2015.11.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Dueck J, Perrin R, Persson GF, Lomax A, Josipovic M, Engelholm SA, Weber DC, Munck P, Rosenschöld AF. SU-F-T-123: The Simulated Effect of the Breath-Hold Reproducibility Treating Locally-Advanced Lung Cancer with Pencil Beam Scanned Proton Therapy. Med Phys 2016. [DOI: 10.1118/1.4956259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Dueck J, Knopf AC, Lomax A, Albertini F, Persson GF, Josipovic M, Aznar M, Weber DC, Munck af Rosenschöld P. Robustness of the Voluntary Breath-Hold Approach for the Treatment of Peripheral Lung Tumors Using Hypofractionated Pencil Beam Scanning Proton Therapy. Int J Radiat Oncol Biol Phys 2016; 95:534-541. [DOI: 10.1016/j.ijrobp.2015.11.015] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 11/04/2015] [Accepted: 11/09/2015] [Indexed: 12/25/2022]
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Mortensen S, Scherman-Rydhög J, Larsen K, Clementsen P, Persson G, Aznar M, Josipovic M, Rosenschöld P, Jølck R, Andresen T, Specht L. PO-0692: A novel endoscopically injected liquid-gel marker for image guided radiotherapy of thoracic tumours. Radiother Oncol 2016. [DOI: 10.1016/s0167-8140(16)31942-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Josipovic M, Persson G, Rydhög J, Bangsgaard J, Specht L, Aznar M. EP-1564: Impact of dose calculation algorithm on SBRT and normofractionated lung radiotherapy in breath hold. Radiother Oncol 2016. [DOI: 10.1016/s0167-8140(16)32814-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Josipovic M, Persson GF, Dueck J, Bangsgaard JP, Westman G, Specht L, Aznar MC. Geometric uncertainties in voluntary deep inspiration breath hold radiotherapy for locally advanced lung cancer. Radiother Oncol 2016; 118:510-4. [PMID: 26631647 DOI: 10.1016/j.radonc.2015.11.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 11/03/2015] [Accepted: 11/08/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND PURPOSE Deep inspiration breath hold (DIBH) increases lung volume and can potentially reduce treatment-related toxicity in locally advanced lung cancer. We estimated geometric uncertainties in visually guided voluntary DIBH and derived the appropriate treatment margins for different image-guidance strategies. MATERIAL AND METHODS Seventeen patients were included prospectively. An optical marker-based respiratory monitoring with visual guidance enabled comfortable DIBHs, adjusted to each patient's performance. All patients had three consecutive DIBH CTs at each of the treatment fractions 2, 16 and 31. DIBH reproducibility was evaluated as inter- and intra-fractional variations in lung volume, tumour position and differential motion between primary tumour and mediastinal lymph nodes. RESULTS Lung volume increased by median 60% in DIBH. Inter- and intra-fractional lung volume variations were median 2.1% and 1.1%, respectively. Inter- and intra-fractional uncertainties in 3D tumour position were 4.8 ± 2.8 mm and 1.7 ± 1.4 mm (mean ± SD). Inter- and intra-fractional differential motion was 4.8 ± 3.3 mm and 0.0 ± 1.1 mm. CONCLUSIONS For single targets, visually guided voluntary DIBH radiotherapy is highly reproducible provided an image-guidance strategy with tumour registration is performed. If the primary tumour is separated from the mediastinal lymph nodes, inter-fractional differential motion remains a challenge and margins must be adapted to reflect the image registration strategy.
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Petersen PM, Aznar MC, Berthelsen AK, Loft A, Schut DA, Maraldo M, Josipovic M, Klausen TL, Andersen FL, Specht L. Prospective phase II trial of image-guided radiotherapy in Hodgkin lymphoma: benefit of deep inspiration breath-hold. Acta Oncol 2015; 54:60-6. [PMID: 25025999 DOI: 10.3109/0284186x.2014.932435] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Long-term Hodgkin lymphoma (HL) survivors have an increased risk of late cardiac morbidity and secondary lung cancer after chemotherapy and mediastinal radiotherapy. In this prospective study we investigate whether radiotherapy with deep inspiration breath-hold (DIBH) can reduce radiation doses to the lungs, heart, and cardiac structures without compromising the target dose. PATIENTS AND METHODS Twenty-two patients (14 female, 8 male), median age 30 years (18-65 years), with supra-diaphragmatic HL were enrolled and had a thoracic PET/CT with DIBH in addition to staging FDG-PET/CT in free breathing (FB) and a planning CT in both FB and DIBH. For each patient an involved-node radiotherapy plan was done for both DIBH and FB, and the doses to the lungs, heart, and female breasts were recorded prospectively. Mean doses to the heart valves and coronary arteries were recorded retrospectively. Patients were treated with the technique yielding the lowest doses to normal structures. RESULTS Nineteen patients were treated with DIBH and three with FB. DIBH reduced the mean estimated lung dose by 2.0 Gy (median: 8.5 Gy vs. 7.2 Gy) (p < 0.01) and the mean heart dose by 1.4 Gy (6.0 Gy vs. 3.9 Gy) (p < 0.01) compared to FB. The lung and heart V20Gy were reduced with a median of 5.3% and 6.3%. Mean doses to the female breasts were equal with FB and DIBH. CONCLUSION DIBH can significantly decrease the estimated mean doses to the heart and lungs without lowering the dose to the target in radiotherapy for patients with mediastinal HL.
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Venter A, Jaars K, Booyens W, Beukes J, van Zyl P, Josipovic M, Hendriks J, Vakkari V, Hellén H, Hakola H, Aaltonen H, Ruiz-Jimenez J, Riekkola ML, Laakso L. Plume characterization of a typical South African braai. SOUTH AFRICAN JOURNAL OF CHEMISTRY 2015. [DOI: 10.17159/0379-4350/2015/v68a25] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Josipovic M, Aznar MC, Persson GF. Deep inspiration breath hold radiotherapy of lung cancer: the good, the bad and the ugly case. Acta Oncol 2014; 53:1446-8. [PMID: 24909375 DOI: 10.3109/0284186x.2014.922216] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Persson G, Josipovic M, Maraldo M, Nygård L, Specht L, Aznar M. Deep Inspiration Breath-Hold Radiation Therapy for Locally Advanced Non-Small Cell Lung Cancer: Is Dose to the Mediastinal Structures Reduced? Int J Radiat Oncol Biol Phys 2014. [DOI: 10.1016/j.ijrobp.2014.05.1843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Thorsen LBJ, Thomsen MS, Berg M, Jensen I, Josipovic M, Overgaard M, Overgaard J, Skogholt P, Offersen BV. CT-planned internal mammary node radiotherapy in the DBCG-IMN study: benefit versus potentially harmful effects. Acta Oncol 2014; 53:1027-34. [PMID: 24957557 DOI: 10.3109/0284186x.2014.925579] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The DBCG-IMN is a nationwide population-based cohort study on the effect of internal mammary node radiotherapy (IMN-RT) in patients with node positive early breast cancer. Due to the risk of RT-induced heart disease, only patients with right-sided breast cancer received IMN-RT, whereas patients with left-sided breast cancer did not. At seven-year median follow-up, a 3% gain in overall survival with IMN-RT has been reported. This study estimates IMN doses and doses to organs at risk (OAR) in patients from the DBCG-IMN. Numbers needed to harm (NNH) if patients with left-sided breast cancer had received IMN-RT are compared to the number needed to treat (NNT). MATERIAL AND METHODS Ten percent of CT-guided treatment plans from the DBCG-IMN patients were selected randomly. IMNs and OAR were contoured in 68 planning CT scans. Dose distributions were re-calculated. IMNs and OAR dose estimates were compared in right-sided versus left-sided breast cancer patients. In six left-sided patients, IMN-RT was simulated, and OAR doses were compared to those in the original plan. The NNH resulting from the change in mean heart dose (MHD) was calculated using a published model for risk of RT-related ischemic heart death. RESULTS In original plans, the absolute difference between right- and left-sided V90% to the IMNs was 38.0% [95% confidence interval (5.5%; 70.5%), p < 0.05]. Heart doses were higher in left-sided plans. With IMN-RT simulation without regard to OAR constraints, MHD increased 4.8 Gy (0.9 Gy; 8.7 Gy), p < 0.05. Resulting NNHs from ischemic heart death were consistently larger than the NNT with IMN-RT. CONCLUSION Refraining from IMN-RT on the left side may have spared some ischemic heart deaths. Assuming left-sided patients benefit as much from IMN-RT as right-sided patients, the benefits from IMN-RT outweigh the costs in terms of ischemic heart death.
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Josipovic M, Persson G, Westman G, Bangsgaard J, Specht L, Aznar M. PO-0931: Image quality and registration uncertainty in image guided deep inspiration breath hold radiotherapy of lung cancer. Radiother Oncol 2014. [DOI: 10.1016/s0167-8140(15)31049-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Dueck J, Knopf A, Albertini F, Persson G, Josipovic M, Aznar M, Lomax T, Munck af Rosenschöld P. PO-0868: Robustness of the breath-hold approach for early stage lung cancer with spot scanned proton therapy. Radiother Oncol 2014. [DOI: 10.1016/s0167-8140(15)30986-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Josipovic M, Persson GF, Håkansson K, Damkjær SMS, Bangsgaard JP, Westman G, Riisgaard S, Specht L, Aznar MC. Deep inspiration breath hold radiotherapy for locally advanced lung cancer: comparison of different treatment techniques on target coverage, lung dose and treatment delivery time. Acta Oncol 2013; 52:1582-6. [PMID: 24047341 DOI: 10.3109/0284186x.2013.813644] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Josipovic M, Persson G, Håkansson K, Damkjær S, Westman G, Bangsgaard J, Specht L, Aznar M. Deep Inspiration Breath-Hold Radiation Therapy for Advanced Stage Lung Cancer Is Feasible and Facilitates Lung Toxicity Reduction. Int J Radiat Oncol Biol Phys 2013. [DOI: 10.1016/j.ijrobp.2013.06.1435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Damkjær SMS, Aznar MC, Pedersen AN, Vogelius IR, Bangsgaard JP, Josipovic M. Reduced lung dose and improved inspiration level reproducibility in visually guided DIBH compared to audio coached EIG radiotherapy for breast cancer patients. Acta Oncol 2013; 52:1458-63. [PMID: 23957594 DOI: 10.3109/0284186x.2013.813073] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Patients with left-sided breast cancer with lymph node involvement have routinely been treated with enhanced inspiration gating (EIG) for a decade at our institution. In a transition from EIG to deep inspiration breath hold (DIBH) we compared the two techniques with focus on target coverage, dose to organs at risk and reproducibility of the inspiration level (IL). MATERIAL AND METHODS Twenty-four patients were computed tomography (CT) scanned with EIG and DIBH. For DIBH we used visual feedback and for EIG audio coaching, both during scan and treatment. Treatment plans for 50 Gy over 25 fractions were calculated. Seventeen of the patients were included in the analysis of reproducibility. They were audio coached for one minute before beam-on in DIBH at nine treatment sessions. These respiration curves were analysed with average maximum IL and standard deviation (SD) for the EIG part of the respiratory signal, and mean IL and SD for the DIBH. Comparison of dosimetric and respiration parameters were performed with the Wilcoxon signed rank-sum test. RESULTS In DIBH, the ipsilateral lung volume increased further compared to EIG (p < 0.0004, mean increase 11%). This lead to a 9% mean reduction (p = 0.002) of the ipsilateral lung volume receiving 20 Gy (V20 Gy). We found no other significant dosimetric differences between the two methods. The reproducibility of the IL was better with the DIBH method, observed as a significantly smaller SD in most patients (p < 0.04 for 16 of 17 patients). CONCLUSION The DIBH method resulted in a significantly larger lung volume and lower ipsilateral lung V20 Gy compared to EIG. The IL for visually guided DIBH was more reproducible than audio-coached EIG. Based on these findings, the DIBH technique is our new breathing adaptation standard for radiotherapy of patients with left-sided breast cancer with lymph node involvement.
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Persson GF, Josipovic M, von der Recke P, Aznar MC, Juhler-Nøttrup T, Munck af Rosenschöld P, Korreman S, Specht L. Stability of percutaneously implanted markers for lung stereotactic radiotherapy. J Appl Clin Med Phys 2013; 14:187-95. [PMID: 24036871 PMCID: PMC5714566 DOI: 10.1120/jacmp.v14i5.4337] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2013] [Revised: 04/26/2013] [Accepted: 04/25/2013] [Indexed: 12/25/2022] Open
Abstract
The purpose of this study was to evaluate the stability of complex markers implanted into lung tumors throughout a course of stereotactic body radiotherapy (SBRT). Fifteen patients referred for lung SBRT were prospectively included. Radio‐opaque markers were implanted percutaneously, guided by computed tomography (CT). Deep inspiration breath‐hold CT scans (BHCT) were acquired at planning and on three treatment days. The treatment days' BHCTs were registered to the planning BHCT. Intraobserver uncertainty in both tumor and marker registration was determined. Deviations in the difference between tumor and marker‐based image registrations of the BHCT scans during treatment quantified the marker stability. Marker position deviation relative to tumor position of less than 2 mm in all three dimensions was considered acceptable for treatment delivery precision. Intra‐observer uncertainties for image registration in the left‐right (LR), anterior‐posterior (AP), craniocaudal (CC) directions and three‐dimensional vector (3D) were 0.9 mm, 0.9 mm, 1.0 mm, and 1.1 mm (SD) for tumor registration and 0.3 mm, 0. 5 mm, 0.7 mm, and 0.7 mm (SD) for marker registration. Mean 3D differences for tumor registrations on all days were significantly larger than for 3D marker registrations (p = 0.007). Overall median differences between tumor and marker position were 0.0 mm (range ‐2.9 to 2.6 mm) in LR, 0.0 mm (‐1.8 to 1.5 mm) in AP, and ‐0.2 mm (‐2.6 to 2.8 mm) in CC directions. Four patients had deviations exceeding 2 mm in one or more registrations throughout the SBRT course. This is the first study to evaluate stability of complex markers implanted percutaneously into lung tumors for image guidance in SBRT. We conclude that the observed stability of marker position within the tumor indicates that complex markers can be used as surrogates for tumor position during a short course of SBRT as long as the uncertainties related to their position within the tumor are incorporated into the planning target volume. PACS number: 87.57.nj, 87.55.ne
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Persson GF, Josipovic M, Nygaard DE, Recke PVD, Aznar M, Juhler-Nøttrup T, Rosenschöld PMA, Korreman S, Specht L. Percutaneously implanted markers in peripheral lung tumours: report of complications. Acta Oncol 2013; 52:1225-8. [PMID: 23398622 DOI: 10.3109/0284186x.2013.764009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Nielsen MH, Berg M, Pedersen AN, Andersen K, Glavicic V, Jakobsen EH, Jensen I, Josipovic M, Lorenzen EL, Nielsen HM, Stenbygaard L, Thomsen MS, Vallentin S, Zimmermann S, Offersen BV. Delineation of target volumes and organs at risk in adjuvant radiotherapy of early breast cancer: national guidelines and contouring atlas by the Danish Breast Cancer Cooperative Group. Acta Oncol 2013; 52:703-10. [PMID: 23421926 DOI: 10.3109/0284186x.2013.765064] [Citation(s) in RCA: 125] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
UNLABELLED During the past decade planning of adjuvant radiotherapy (RT) of early breast cancer has changed from two-dimensional (2D) to 3D conformal techniques. In the planning computerised tomography (CT) scan both the targets for RT and the organs at risk (OARs) are visualised, enabling an increased focus on target dose coverage and homogeneity with only minimal dose to the OARs. To ensure uniform RT in the national prospective trials of the Danish Breast Cancer Cooperative Group (DBCG), a national consensus for the delineation of clinical target volumes (CTVs) and OARs was required. MATERIAL AND METHODS A CT scan of a breast cancer patient after surgical breast conservation and axillary lymph node (LN) dissection was used for delineation. During multiple dummy-runs seven experienced radiation oncologists contoured all CTVs and OARs of interest in adjuvant breast RT. Two meetings were held in the DBCG Radiotherapy Committee to discuss the contouring and to approve a final consensus. The Dice similarity coefficient (DSC) was used to evaluate the delineation agreement before and after the consensus. RESULTS The consensus delineations of CTVs and OARs are available online and a table is presented with a contouring description of the individual volumes. The consensus provides recommendations for target delineation in a standard patient both in case of breast conservation or mastectomy. Before the consensus, the average value of the DSC was modest for most volumes, but high for the breast CTV and the heart. After the consensus, the DSC increased for all volumes. CONCLUSION The DBCG has provided the first national guidelines and a contouring atlas of CTVs and OARs definition for RT of early breast cancer. The DSC is a useful tool in quantifying the effect of the introduction of guidelines indicating improved inter-delineator agreement. This consensus will be used by the DBCG in our prospective trials.
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Josipovic M, Damkjær S, Håkansson K, Aznar M, Bangsgaard J, Westman G, Fredberg Persson G. PO-0880: Voluntary deep inspiration breath hold for locally advanced lung cancer radiotherapy is feasible and reproducible. Radiother Oncol 2013. [DOI: 10.1016/s0167-8140(15)33186-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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81
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Persson G, Josipovic M, Nygaard D, Aznar M, Munck af Rosenschöld P, von der Recke P, Juhler-Nøttrup T, Korreman S, Specht L. Feasibility and Stability of Transthoracic Implanted Markers in Peripheral Lung Tumors for Stereotactic Body Radiation Therapy. Int J Radiat Oncol Biol Phys 2012. [DOI: 10.1016/j.ijrobp.2012.07.520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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82
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Aznar M, Maraldo M, Brodin N, Josipovic M, Petersen P, Vogelius I, Berthelsen A, Loft A, Damkjaer S, Specht L. PD-0487 DEEP-INSPIRATION BREATH-HOLD REDUCES THE RISK OF CARDIAC TOXICITY AND SECONDARY LUNG CANCER AFTER HODGKIN LYMPHOMA. Radiother Oncol 2012. [DOI: 10.1016/s0167-8140(12)70826-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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83
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Josipovic M, Persson GF, Logadottir A, Smulders B, Westmann G, Bangsgaard JP. Translational and rotational intra- and inter-fractional errors in patient and target position during a short course of frameless stereotactic body radiotherapy. Acta Oncol 2012; 51:610-7. [PMID: 22263924 DOI: 10.3109/0284186x.2011.626448] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Implementation of cone beam computed tomography (CBCT) in frameless stereotactic body radiotherapy (SBRT) of lung tumours enables setup correction based on tumour position. The aim of this study was to compare setup accuracy with daily soft tissue matching to bony anatomy matching and evaluate intra- and inter-fractional translational and rotational errors in patient and target positions. MATERIAL AND METHODS Fifteen consecutive SBRT patients were included in the study. Vacuum cushions were used for immobilisation. SBRT plans were based on midventilation phase of four-dimensional (4D)-CT or three-dimensional (3D)-CT from PET/CT. Margins of 5 mm in the transversal plane and 10 mm in the cranio-caudal (CC) direction were applied. SBRT was delivered in three fractions within a week. At each fraction, CBCT was performed before and after the treatment. Setup accuracy comparison between soft tissue matching and bony anatomy matching was evaluated on pretreatment CBCTs. From differences in pre- and post-treatment CBCTs, we evaluated the extent of translational and rotational intra-fractional changes in patient position, tumour position and tumour baseline shift. All image registration was rigid with six degrees of freedom. RESULTS The median 3D difference between patient position based on bony anatomy matching and soft tissue matching was 3.0 mm (0-8.3 mm). The median 3D intra-fractional change in patient position was 1.4 mm (0-12.2 mm) and 2.2 mm (0-13.2 mm) in tumour position. The median 3D intra-fractional baseline shift was 2.2 mm (0-4.7 mm). With correction of translational errors, the remaining systematic and random errors were approximately 1°. CONCLUSION . Soft tissue tumour matching improved precision of treatment delivery in frameless SBRT of lung tumours compared to image guidance using bone matching. The intra-fractional displacement of the target position was affected by both translational and rotational changes in tumour baseline position relative to the bony anatomy and by changes in patient position.
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Aznar MC, Korreman SS, Pedersen AN, Persson GF, Josipovic M, Specht L. Evaluation of dose to cardiac structures during breast irradiation. Br J Radiol 2011; 84:743-6. [PMID: 21159806 PMCID: PMC3473433 DOI: 10.1259/bjr/12497075] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Revised: 06/01/2010] [Accepted: 06/10/2010] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Adjuvant radiotherapy for breast cancer can lead to late cardiac complications. The highest radiation doses are likely to be to the anterior portion of the heart, including the left anterior descending coronary artery (LAD). The purpose of this work was to assess the radiation doses delivered to the heart and the LAD in respiration-adapted radiotherapy of patients with left-sided breast cancer. METHODS 24 patients referred for adjuvant radiotherapy after breast-conserving surgery for left-sided lymph node positive breast cancer were evaluated. The whole heart, the arch of the LAD and the whole LAD were contoured. The radiation doses to all three cardiac structures were evaluated. RESULTS For 13 patients, the plans were acceptable based on the criteria set for all 3 contours. For seven patients, the volume of heart irradiated was well below the set clinical threshold whereas a high dose was still being delivered to the LAD. In 1 case, the dose to the LAD was low while 19% of the contoured heart volume received over 20 Gy. In five patients, the dose to the arch LAD was relatively low while the dose to the whole LAD was considerably higher. CONCLUSION This study indicates that it is necessary to assess the dose delivered to the whole heart as well as to the whole LAD when investigating the acceptability of a breast irradiation treatment. Assessing the dose to only one of these structures could lead to excessive heart irradiation and thereby increased risk of cardiac complications for breast cancer radiotherapy patients.
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Knudsen J, Nauntofte B, Josipovic M, Engelholm SA, Hyldegaard O. Effects of Isoflurane Anesthesia and Pilocarpine on Rat Parotid Saliva Flow. Radiat Res 2011; 176:84-8. [DOI: 10.1667/rr2304.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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86
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Aznar M, Andersen F, Berthelsen A, Josipovic M, Klausen T, Loft A, Olsen M, Petersen P, Specht L. Feasibility of breathing-adapted PET/CT imaging for radiation therapy of Hodgkin lymphoma. Cancer Imaging 2011. [DOI: 10.1102/1470-7330.2011.9063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Josipovic M, Nygaard D, Persson G, Zacharatou C, Bangsgaard J, Korreman S. Changes in Dose Coverage during Respiration in Lung Cancer Radiotherapy. Int J Radiat Oncol Biol Phys 2010. [DOI: 10.1016/j.ijrobp.2010.07.1737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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