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Finnegan RN, Quinn A, Booth J, Belous G, Hardcastle N, Stewart M, Griffiths B, Carroll S, Thwaites DI. Cardiac substructure delineation in radiation therapy - A state-of-the-art review. J Med Imaging Radiat Oncol 2024. [PMID: 38757728 DOI: 10.1111/1754-9485.13668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 04/29/2024] [Indexed: 05/18/2024]
Abstract
Delineation of cardiac substructures is crucial for a better understanding of radiation-related cardiotoxicities and to facilitate accurate and precise cardiac dose calculation for developing and applying risk models. This review examines recent advancements in cardiac substructure delineation in the radiation therapy (RT) context, aiming to provide a comprehensive overview of the current level of knowledge, challenges and future directions in this evolving field. Imaging used for RT planning presents challenges in reliably visualising cardiac anatomy. Although cardiac atlases and contouring guidelines aid in standardisation and reduction of variability, significant uncertainties remain in defining cardiac anatomy. Coupled with the inherent complexity of the heart, this necessitates auto-contouring for consistent large-scale data analysis and improved efficiency in prospective applications. Auto-contouring models, developed primarily for breast and lung cancer RT, have demonstrated performance comparable to manual contouring, marking a significant milestone in the evolution of cardiac delineation practices. Nevertheless, several key concerns require further investigation. There is an unmet need for expanding cardiac auto-contouring models to encompass a broader range of cancer sites. A shift in focus is needed from ensuring accuracy to enhancing the robustness and accessibility of auto-contouring models. Addressing these challenges is paramount for the integration of cardiac substructure delineation and associated risk models into routine clinical practice, thereby improving the safety of RT for future cancer patients.
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Affiliation(s)
- Robert N Finnegan
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Institute of Medical Physics, School of Physics, University of Sydney, Sydney, New South Wales, Australia
| | - Alexandra Quinn
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Jeremy Booth
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Institute of Medical Physics, School of Physics, University of Sydney, Sydney, New South Wales, Australia
| | - Gregg Belous
- Australian e-Health Research Centre, Commonwealth Scientific and Industrial Research Organisation, Brisbane, Queensland, Australia
| | - Nicholas Hardcastle
- Department of Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Maegan Stewart
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia
- School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Brooke Griffiths
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Susan Carroll
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia
- School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - David I Thwaites
- Institute of Medical Physics, School of Physics, University of Sydney, Sydney, New South Wales, Australia
- Radiotherapy Research Group, Leeds Institute of Medical Research, St James's Hospital and University of Leeds, Leeds, UK
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Kovacs B, Lehmann HI, Manninger M, Saguner AM, Futyma P, Duncker D, Chun J. Stereotactic arrhythmia radioablation and its implications for modern cardiac electrophysiology: results of an EHRA survey. Europace 2024; 26:euae110. [PMID: 38666444 PMCID: PMC11086561 DOI: 10.1093/europace/euae110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 04/23/2024] [Indexed: 05/12/2024] Open
Abstract
Stereotactic arrhythmia radioablation (STAR) is a treatment option for recurrent ventricular tachycardia/fibrillation (VT/VF) in patients with structural heart disease (SHD). The current and future role of STAR as viewed by cardiologists is unknown. The study aimed to assess the current role, barriers to application, and expected future role of STAR. An online survey consisting of 20 questions on baseline demographics, awareness/access, current use, and the future role of STAR was conducted. A total of 129 international participants completed the survey [mean age 43 ± 11 years, 25 (16.4%) female]. Ninety-one (59.9%) participants were electrophysiologists. Nine participants (7%) were unaware of STAR as a therapeutic option. Sixty-four (49.6%) had access to STAR, while 62 (48.1%) had treated/referred a patient for treatment. Common primary indications for STAR were recurrent VT/VF in SHD (45%), recurrent VT/VF without SHD (7.8%), or premature ventricular contraction (3.9%). Reported main advantages of STAR were efficacy in the treatment of arrhythmias not amenable to conventional treatment (49%) and non-invasive treatment approach with overall low expected acute and short-term procedural risk (23%). Most respondents have foreseen a future clinical role of STAR in the treatment of VT/VF with or without underlying SHD (72% and 75%, respectively), although only a minority expected a first-line indication for it (7% and 5%, respectively). Stereotactic arrhythmia radioablation as a novel treatment option of recurrent VT appears to gain acceptance within the cardiology community. Further trials are critical to further define efficacy, patient populations, as well as the appropriate clinical use for the treatment of VT.
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Affiliation(s)
- Boldizsar Kovacs
- Department of Cardiology, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, 48109 MI, USA
- Department of Cardiology, University Heart Center Zurich, Raemistrasse 100, Zurich 8091, Switzerland
| | - Helge Immo Lehmann
- Department of Cardiology, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, 48109 MI, USA
- Corrigan Minehan Heart Center, Massachusetts General Hospital, 55 Fruit St, Boston, 02114 MA, USA
| | - Martin Manninger
- Division of Cardiology, Department of Medicine, Medical University of Graz, Graz, Austria
| | - Ardan Muammer Saguner
- Department of Cardiology, University Heart Center Zurich, Raemistrasse 100, Zurich 8091, Switzerland
| | - Piotr Futyma
- Medical College, University of Rzeszów and St. Joseph’s Heart Rhythm Center, Rzeszów, Poland
| | - David Duncker
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Julian Chun
- Cardioangiologisches Centrum Bethanien, Agaplesion Bethanien Krankenhaus, Frankfurt, Germany
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Liulu X, Balaji P, Barber J, De Silva K, Murray T, Hickey A, Campbell T, Harris J, Gee H, Ahern V, Kumar S, Hau E, Qian PC. Radiation therapy for ventricular arrhythmias. J Med Imaging Radiat Oncol 2024. [PMID: 38698577 DOI: 10.1111/1754-9485.13662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 04/15/2024] [Indexed: 05/05/2024]
Abstract
Ventricular arrhythmias (VA) can be life-threatening arrhythmias that result in significant morbidity and mortality. Catheter ablation (CA) is an invasive treatment modality that can be effective in the treatment of VA where medications fail. Recurrence occurs commonly following CA due to an inability to deliver lesions of adequate depth to cauterise the electrical circuits that drive VA or reach areas of scar responsible for VA. Stereotactic body radiotherapy is a non-invasive treatment modality that allows volumetric delivery of energy to treat circuits that cannot be reached by CA. It overcomes the weaknesses of CA and has been successfully utilised in small clinical trials to treat refractory VA. This article summarises the current evidence for this novel treatment modality and the steps that will be required to bring it to the forefront of VA treatment.
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Affiliation(s)
- Xingzhou Liulu
- Cardiology Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Poornima Balaji
- Cardiology Department, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
- Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Jeffrey Barber
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Kasun De Silva
- Cardiology Department, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
- Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Tiarne Murray
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
| | - Andrew Hickey
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
| | - Timothy Campbell
- Cardiology Department, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
- Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Jill Harris
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
| | - Harriet Gee
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Verity Ahern
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Saurabh Kumar
- Cardiology Department, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
- Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Eric Hau
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
- Translational Radiation Biology and Oncology Laboratory, Centre for Cancer Research, The Westmead Institute for Medical Research, Sydney, New South Wales, Australia
- Blacktown Hematology and Cancer Centre, Blacktown Hospital, Blacktown, New South Wales, Australia
| | - Pierre C Qian
- Cardiology Department, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
- Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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Poon J, Thompson RB, Deyell MW, Schellenberg D, Clark H, Reinsberg S, Thomas S. Analysis of left ventricle regional myocardial motion for cardiac radioablation: Left ventricular motion analysis. J Appl Clin Med Phys 2024; 25:e14333. [PMID: 38493500 PMCID: PMC11087184 DOI: 10.1002/acm2.14333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 02/06/2024] [Accepted: 02/20/2024] [Indexed: 03/19/2024] Open
Abstract
PURPOSE Left ventricle (LV) regional myocardial displacement due to cardiac motion was assessed using cardiovascular magnetic resonance (CMR) cine images to establish region-specific margins for cardiac radioablation treatments. METHODS CMR breath-hold cine images and LV myocardial tissue contour points were analyzed for 200 subjects, including controls (n = 50) and heart failure (HF) patients with preserved ejection fraction (HFpEF, n = 50), mid-range ejection fraction (HFmrEF, n = 50), and reduced ejection fraction (HFrEF, n = 50). Contour points were divided into segments according to the 17-segment model. For each patient, contour point displacements were determined for the long-axis (all 17 segments) and short-axis (segments 1-12) directions. Mean overall, tangential (longitudinal or circumferential), and normal (radial) displacements were calculated for the 17 segments and for each segment level. RESULTS The greatest overall motion was observed in the control group-long axis: 4.5 ± 1.2 mm (segment 13 [apical anterior] epicardium) to 13.8 ± 3.0 mm (segment 6 [basal anterolateral] endocardium), short axis: 4.3 ± 0.8 mm (segment 9 [mid inferoseptal] epicardium) to 11.5 ± 2.3 mm (segment 1 [basal anterior] endocardium). HF patients exhibited lesser motion, with the smallest overall displacements observed in the HFrEF group-long axis: 4.3 ± 1.7 mm (segment 13 [apical anterior] epicardium) to 10.6 ± 3.4 mm (segment 6 [basal anterolateral] endocardium), short axis: 3.9 ± 1.3 mm (segment 8 [mid anteroseptal] epicardium) to 7.4 ± 2.8 mm (segment 1 [basal anterior] endocardium). CONCLUSIONS This analysis provides an estimate of epicardial and endocardial displacement for the 17 segments of the LV for patients with normal and impaired LV function. This reference data can be used to establish treatment planning margin guidelines for cardiac radioablation. Smaller margins may be used for patients with higher degree of impaired heart function, depending on the LV segment.
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Affiliation(s)
- Justin Poon
- Department of Physics and AstronomyUniversity of British ColumbiaVancouverBritish ColumbiaCanada
- Department of Medical PhysicsBC CancerVancouverBritish ColumbiaCanada
| | - Richard B. Thompson
- Department of Biomedical EngineeringUniversity of AlbertaEdmontonAlbertaCanada
| | - Marc W. Deyell
- Heart Rhythm ServicesDivision of CardiologyUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | | | - Haley Clark
- Department of Physics and AstronomyUniversity of British ColumbiaVancouverBritish ColumbiaCanada
- Department of Medical PhysicsBC CancerSurreyBritish ColumbiaCanada
| | - Stefan Reinsberg
- Department of Physics and AstronomyUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Steven Thomas
- Department of Medical PhysicsBC CancerVancouverBritish ColumbiaCanada
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Haberl C, Crean AM, Zelt JGE, Redpath CJ, deKemp RA. Role of Nuclear Imaging in Cardiac Stereotactic Body Radiotherapy for Ablation of Ventricular Tachycardia. Semin Nucl Med 2024; 54:427-437. [PMID: 38658301 DOI: 10.1053/j.semnuclmed.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 03/19/2024] [Indexed: 04/26/2024]
Abstract
Ventricular tachycardia (VT) is a life-threatening arrhythmia common in patients with structural heart disease or nonischemic cardiomyopathy. Many VTs originate from regions of fibrotic scar tissue, where delayed electrical signals exit scar and re-enter viable myocardium. Cardiac stereotactic body radiotherapy (SBRT) has emerged as a completely noninvasive alternative to catheter ablation for the treatment of recurrent or refractory ventricular tachycardia. While there is no common consensus on the ideal imaging workflow, therapy planning for cardiac SBRT often combines information from a plurality of imaging modalities including MRI, CT, electroanatomic mapping and nuclear imaging. MRI and CT provide detailed anatomic information, and late enhancement contrast imaging can indicate regions of fibrosis. Electroanatomic maps indicate regions of heterogenous conduction voltage or early activation which are indicative of arrhythmogenic tissue. Some early clinical adopters performing cardiac SBRT report the use of myocardial perfusion and viability nuclear imaging to identify regions of scar. Nuclear imaging of hibernating myocardium, inflammation and sympathetic innervation have been studied for ventricular arrhythmia prognosis and in research relating to catheter ablation of VT but have yet to be studied in their potential applications for cardiac SBRT. The integration of information from these many imaging modalities to identify a target for ablation can be challenging. Multimodality image registration and dedicated therapy planning tools may enable higher target accuracy, accelerate therapy planning workflows and improve patient outcomes. Understanding the pathophysiology of ventricular arrhythmias, and localizing the arrhythmogenic tissues, is vital for successful ablation with cardiac SBRT. Nuclear imaging provides an arsenal of imaging strategies to identify regional scar, hibernation, inflammation, and sympathetic denervation with some advantages over alternative imaging strategies.
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Affiliation(s)
- Connor Haberl
- University of Ottawa Heart Institute, Ottawa, ON; Carleton University, Ottawa, ON
| | - Andrew M Crean
- University of Ottawa Heart Institute, Ottawa, ON; North West Heart Center, University of Manchester Foundation NHS Trust, Manchester, UK
| | - Jason G E Zelt
- The Ottawa Hospital, Ottawa, ON; Department of Medicine, University of Ottawa, Ottawa, ON
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Akdag O, Borman PTS, Mandija S, Woodhead PL, Uijtewaal P, Raaymakers BW, Fast MF. Experimental demonstration of real-time cardiac physiology-based radiotherapy gating for improved cardiac radioablation on an MR-linac. Med Phys 2024; 51:2354-2366. [PMID: 38477841 DOI: 10.1002/mp.17024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 02/09/2024] [Accepted: 02/23/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Cardiac radioablation is a noninvasive stereotactic body radiation therapy (SBRT) technique to treat patients with refractory ventricular tachycardia (VT) by delivering a single high-dose fraction to the VT isthmus. Cardiorespiratory motion induces position uncertainties resulting in decreased dose conformality. Electocardiograms (ECG) are typically used during cardiac MRI (CMR) to acquire images in a predefined cardiac phase, thus mitigating cardiac motion during image acquisition. PURPOSE We demonstrate real-time cardiac physiology-based radiotherapy beam gating within a preset cardiac phase on an MR-linac. METHODS MR images were acquired in healthy volunteers (n = 5, mean age = 29.6 years, mean heart-rate (HR) = 56.2 bpm) on the 1.5 T Unity MR-linac (Elekta AB, Stockholm, Sweden) after obtaining written informed consent. The images were acquired using a single-slice balance steady-state free precession (bSSFP) sequence in the coronal or sagittal plane (TR/TE = 3/1.48 ms, flip angle = 48∘ $^{\circ }$ , SENSE = 1.5,field-of-view = 400 × 207 $\text{field-of-view} = {400}\times {207}$ mm 2 ${\text{mm}}^{2}$ , voxel size =3 × 3 × 15 $3\times 3\times 15$ mm 3 ${\rm mm}^{3}$ , partial Fourier factor = 0.65, frame rate = 13.3 Hz). In parallel, a 4-lead ECG-signal was acquired using MR-compatible equipment. The feasibility of ECG-based beam gating was demonstrated with a prototype gating workflow using a Quasar MRI4D motion phantom (IBA Quasar, London, ON, Canada), which was deployed in the bore of the MR-linac. Two volunteer-derived combined ECG-motion traces (n = 2, mean age = 26 years, mean HR = 57.4 bpm, peak-to-peak amplitude = 14.7 mm) were programmed into the phantom to mimic dose delivery on a cardiac target in breath-hold. Clinical ECG-equipment was connected to the phantom for ECG-voltage-streaming in real-time using research software. Treatment beam gating was performed in the quiescent phase (end-diastole). System latencies were compensated by delay time correction. A previously developed MRI-based gating workflow was used as a benchmark in this study. A 15-beam intensity-modulated radiotherapy (IMRT) plan (1 × 6.25 ${1}\times {6.25}$ Gy) was delivered for different motion scenarios onto radiochromic films. Next, cardiac motion was then estimated at the basal anterolateral myocardial wall via normalized cross-correlation-based template matching. The estimated motion signal was temporally aligned with the ECG-signal, which were then used for position- and ECG-based gating simulations in the cranial-caudal (CC), anterior-posterior (AP), and right-left (RL) directions. The effect of gating was investigated by analyzing the differences in residual motion at 30, 50, and 70% treatment beam duty cycles. RESULTS ECG-based (MRI-based) beam gating was performed with effective duty cycles of 60.5% (68.8%) and 47.7% (50.4%) with residual motion reductions of 62.5% (44.7%) and 43.9% (59.3%). Local gamma analyses (1%/1 mm) returned pass rates of 97.6% (94.1%) and 90.5% (98.3%) for gated scenarios, which exceed the pass rates of 70.3% and 82.0% for nongated scenarios, respectively. In average, the gating simulations returned maximum residual motion reductions of 88%, 74%, and 81% at 30%, 50%, and 70% duty cycles, respectively, in favor of MRI-based gating. CONCLUSIONS Real-time ECG-based beam gating is a feasible alternative to MRI-based gating, resulting in improved dose delivery in terms of highγ -pass $\gamma {\text{-pass}}$ rates, decreased dose deposition outside the PTV and residual motion reduction, while by-passing cardiac MRI challenges.
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Affiliation(s)
- Osman Akdag
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Pim T S Borman
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Stefano Mandija
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
- Computational Imaging Group for MR Diagnostics and Therapy, Center for Image Sciences, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Peter L Woodhead
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
- Elekta AB, Stockholm, Sweden
| | - Prescilla Uijtewaal
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Bas W Raaymakers
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Martin F Fast
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
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Poon J, Thompson RB, Deyell MW, Schellenberg D, Kohli K, Thomas S. Left ventricle segment-specific motion assessment for cardiac-gated radiosurgery. Biomed Phys Eng Express 2024; 10:025040. [PMID: 38359447 DOI: 10.1088/2057-1976/ad29a4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/15/2024] [Indexed: 02/17/2024]
Abstract
Purpose.Cardiac radiosurgery is a non-invasive treatment modality for ventricular tachycardia, where a linear accelerator is used to irradiate the arrhythmogenic region within the heart. In this work, cardiac magnetic resonance (CMR) cine images were used to quantify left ventricle (LV) segment-specific motion during the cardiac cycle and to assess potential advantages of cardiac-gated radiosurgery.Methods.CMR breath-hold cine images and LV contour points were analyzed for 50 controls and 50 heart failure patients with reduced ejection fraction (HFrEF, EF < 40%). Contour points were divided into anatomic segments according to the 17-segment model, and each segment was treated as a hypothetical treatment target. The optimum treatment window (one fifth of the cardiac cycle) was determined where segment centroid motion was minimal, then the maximum centroid displacement and treatment area were determined for the full cardiac cycle and for the treatment window. Mean centroid displacement and treatment area reductions with cardiac gating were determined for each of the 17 segments.Results.Full motion segment centroid displacements ranged between 6-14 mm (controls) and 4-11 mm (HFrEF). Full motion treatment areas ranged between 129-715 mm2(controls) and 149-766 mm2(HFrEF). With gating, centroid displacements were reduced to 1 mm (controls and HFrEF), while treatment areas were reduced to 62-349 mm2(controls) and 83-393 mm2(HFrEF). Relative treatment area reduction ranged between 38%-53% (controls) and 26%-48% (HFrEF).Conclusion.This data demonstrates that cardiac cycle motion is an important component of overall target motion and varies depending on the anatomic cardiac segment. Accounting for cardiac cycle motion, through cardiac gating, has the potential to significantly reduce treatment volumes for cardiac radiosurgery.
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Affiliation(s)
- Justin Poon
- Department of Physics and Astronomy, University of British Columbia, Vancouver, BC V6T 1Z1, Canada
- Department of Medical Physics, BC Cancer, Vancouver, British Columbia V5Z 4E6, Canada
| | - Richard B Thompson
- Department of Biomedical Engineering, University of Alberta, Edmonton, AB, T6G 2V2, Canada
| | - Marc W Deyell
- Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, BC V6E 1M7, Canada
| | - Devin Schellenberg
- Department of Radiation Oncology, BC Cancer, Surrey, British Columbia V3V 1Z2, Canada
| | - Kirpal Kohli
- Department of Medical Physics, BC Cancer, Surrey, British Columbia V3V 1Z2, Canada
| | - Steven Thomas
- Department of Medical Physics, BC Cancer, Vancouver, British Columbia V5Z 4E6, Canada
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8
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Stevens RRF, Hazelaar C, Bogowicz M, Ter Bekke RMA, Volders PGA, Verhoeven K, de Ruysscher D, Verhoeff JJC, Fast MF, Mandija S, Cvek J, Knybel L, Dvorak P, Blanck O, van Elmpt W. A Framework for Assessing the Effect of Cardiac and Respiratory Motion for Stereotactic Arrhythmia Radioablation Using a Digital Phantom With a 17-Segment Model: A STOPSTORM.eu Consortium Study. Int J Radiat Oncol Biol Phys 2024; 118:533-542. [PMID: 37652302 DOI: 10.1016/j.ijrobp.2023.08.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 08/14/2023] [Accepted: 08/22/2023] [Indexed: 09/02/2023]
Abstract
PURPOSE The optimal motion management strategy for patients receiving stereotactic arrhythmia radioablation (STAR) for the treatment of ventricular tachycardia (VT) is not fully known. We developed a framework using a digital phantom to simulate cardiorespiratory motion in combination with different motion management strategies to gain insight into the effect of cardiorespiratory motion on STAR. METHODS AND MATERIALS The 4-dimensional (4D) extended cardiac-torso (XCAT) phantom was expanded with the 17-segment left ventricular (LV) model, which allowed placement of STAR targets in standardized ventricular regions. Cardiac- and respiratory-binned 4D computed tomography (CT) scans were simulated for free-breathing, reduced free-breathing, respiratory-gating, and breath-hold scenarios. Respiratory motion of the heart was set to population-averaged values of patients with VT: 6, 2, and 1 mm in the superior-inferior, posterior-anterior, and left-right direction, respectively. Cardiac contraction was adjusted by reducing LV ejection fraction to 35%. Target displacement was evaluated for all segments using envelopes encompassing the cardiorespiratory motion. Envelopes incorporating only the diastole plus respiratory motion were created to simulate the scenario where cardiac motion is not fully captured on 4D respiratory CT scans used for radiation therapy planning. RESULTS The average volume of the 17 segments was 6 cm3 (1-9 cm3). Cardiac contraction-relaxation resulted in maximum segment (centroid) motion of 4, 6, and 3.5 mm in the superior-inferior, posterior-anterior, and left-right direction, respectively. Cardiac contraction-relaxation resulted in a motion envelope increase of 49% (24%-79%) compared with individual segment volumes, whereas envelopes increased by 126% (79%-167%) if respiratory motion also was considered. Envelopes incorporating only the diastole and respiration motion covered on average 68% to 75% of the motion envelope. CONCLUSIONS The developed LV-segmental XCAT framework showed that free-wall regions display the most cardiorespiratory displacement. Our framework supports the optimization of STAR by evaluating the effect of (cardio)respiratory motion and motion management strategies for patients with VT.
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Affiliation(s)
- Raoul R F Stevens
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Center+, Maastricht, The Netherlands.
| | - Colien Hazelaar
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Marta Bogowicz
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Rachel M A Ter Bekke
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Paul G A Volders
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Karolien Verhoeven
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Dirk de Ruysscher
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Joost J C Verhoeff
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Martin F Fast
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Stefano Mandija
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jakub Cvek
- Department of Oncology, University Hospital and Faculty of Medicine, Ostrava, Czech Republic
| | - Lukas Knybel
- Department of Oncology, University Hospital and Faculty of Medicine, Ostrava, Czech Republic
| | - Pavel Dvorak
- Department of Oncology, University Hospital and Faculty of Medicine, Ostrava, Czech Republic
| | - Oliver Blanck
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Wouter van Elmpt
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Center+, Maastricht, The Netherlands
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Rigal L, Benali K, Barré V, Bougault M, Bellec J, Crevoisier RD, Martins R, Simon A. Multimodal fusion workflow for target delineation in cardiac radioablation of ventricular tachycardia. Med Phys 2024; 51:292-305. [PMID: 37455674 DOI: 10.1002/mp.16613] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 06/12/2023] [Accepted: 06/22/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Cardiac radioablation (CR) is an innovative treatment to ablate cardiac arrythmia sources by radiation therapy. CR target delineation is a challenging task requiring the exploitation of highly different imaging modalities, including cardiac electro-anatomical mapping (EAM). PURPOSE In this work, a data integration process is proposed to alleviate the tediousness of CR target delineation by generating a fused representation of the heart, including all the information of interest resulting from the analysis and registration of electro-anatomical data, PET scan and planning computed tomography (CT) scan. The proposed process was evaluated by cardiologists during delineation trials. METHODS The data processing pipeline was composed of the following steps. The cardiac structures of interest were segmented from cardiac CT scans using a deep learning method. The EAM data was registered to the cardiac CT scan using a point cloud based registration method. The PET scan was registered using rigid image registration. The EAM and PET information, as well as the myocardium thickness, were projected on the surface of the 3D mesh of the left ventricle. The target was identified by delineating a path on this surface that was further projected to the thickness of the myocardium to create the target volume. This process was evaluated by comparison with a standard slice-by-slice delineation with mental EAM registration. Four cardiologists delineated targets for three patients using both methods. The variability of target volumes, and the ease of use of the proposed method, were evaluated. RESULTS All cardiologists reported being more confident and efficient using the proposed method. The inter-clinician variability in delineated target volume was systematically lower with the proposed method (average dice score of 0.62 vs. 0.32 with a classical method). Delineation times were also improved. CONCLUSIONS A data integration process was proposed and evaluated to fuse images of interest for CR target delineation. It effectively reduces the tediousness of CR target delineation, while improving inter-clinician agreement on target volumes. This study is still to be confirmed by including more clinicians and patient data to the experiments.
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Affiliation(s)
- Louis Rigal
- Univ Rennes, CHU Rennes, CLCC Eugène Marquis, Inserm, LTSI - UMR 1099, Rennes, France
| | - Karim Benali
- Univ Rennes, CHU Rennes, CLCC Eugène Marquis, Inserm, LTSI - UMR 1099, Rennes, France
- Department of Cardiology, Saint-Etienne University Hospital, Saint-Priest-En-Jarez, France
| | - Valentin Barré
- Department of Cardiology, Rennes University Hospital, Rennes, France
| | - Mathilde Bougault
- Department of Cardiology, Rennes University Hospital, Rennes, France
| | - Julien Bellec
- Department of Cardiology, Rennes University Hospital, Rennes, France
- Medical Physics Department, CLCC Eugène Marquis, Rennes, France
| | - Renaud De Crevoisier
- Univ Rennes, CHU Rennes, CLCC Eugène Marquis, Inserm, LTSI - UMR 1099, Rennes, France
| | - Raphaël Martins
- Univ Rennes, CHU Rennes, CLCC Eugène Marquis, Inserm, LTSI - UMR 1099, Rennes, France
| | - Antoine Simon
- Univ Rennes, CHU Rennes, CLCC Eugène Marquis, Inserm, LTSI - UMR 1099, Rennes, France
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10
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Walls GM, Ghita M, Herron B, Edgar KS, Kuburas R, Watson CJ, Grieve DJ, Cole AJ, Jain S, Butterworth KT. A multimodality assessment of the protective capacity of statin therapy in a mouse model of radiation cardiotoxicity. Radiother Oncol 2024; 190:110004. [PMID: 37972738 DOI: 10.1016/j.radonc.2023.110004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE Despite technological advances in radiotherapy (RT), cardiotoxicity remains a common complication in patients with lung, oesophageal and breast cancers. Statin therapy has been shown to have pleiotropic properties beyond its lipid-lowering effects. Previous murine models have shown statin therapy can reduce short-term functional effects of whole-heart irradiation. In this study, we assessed the efficacy of atorvastatin in protecting against the late effects of radiation exposure on systolic function, cardiac conduction, and atrial natriuretic peptide (ANP) following a clinically relevant partial-heart radiation exposure. MATERIALS AND METHODS Female, 12-week old, C57BL/6j mice received an image-guided 16 Gy X-ray field to the base of the heart using a small animal radiotherapy research platform (SARRP), with or without atorvastatin from 1 week prior to irradiation until the end of the experiment. The animals were followed for 50 weeks with longitudinal transthoracic echocardiography (TTE) and electrocardiography (ECG) every 10 weeks, and plasma ANP every 20 weeks. RESULTS At 30-50 weeks, mild left ventricular systolic function impairment observed in the RT control group was less apparent in animals receiving atorvastatin. ECG analysis demonstrated prolongation of components of cardiac conduction related to the heart base at 10 and 30 weeks in the RT control group but not in animals treated with atorvastatin. In contrast to systolic function, conduction disturbances resolved at later time-points with radiation alone. ANP reductions were lower in irradiated animals receiving atorvastatin at 30 and 50 weeks. CONCLUSIONS Atorvastatin prevents left ventricular systolic dysfunction, and the perturbation of cardiac conduction following partial heart irradiation. If confirmed in clinical studies, these data would support the use of statin therapy for cardioprotection during thoracic radiotherapy.
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Affiliation(s)
- Gerard M Walls
- Cancer Centre Belfast City Hospital, Belfast Health & Social Care Trust, Lisburn Road, Belfast, UK; Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Jubilee Road, Belfast, UK.
| | - Mihaela Ghita
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Jubilee Road, Belfast, UK
| | - Brian Herron
- Department of Histopathology Royal Victoria Hospital, Belfast Health & Social Care Trust, Falls Road, Belfast, UK
| | - Kevin S Edgar
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Jubilee Road, Belfast, UK
| | - Refik Kuburas
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Jubilee Road, Belfast, UK
| | - Chris J Watson
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Jubilee Road, Belfast, UK
| | - David J Grieve
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Jubilee Road, Belfast, UK
| | - Aidan J Cole
- Cancer Centre Belfast City Hospital, Belfast Health & Social Care Trust, Lisburn Road, Belfast, UK; Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Jubilee Road, Belfast, UK
| | - Suneil Jain
- Cancer Centre Belfast City Hospital, Belfast Health & Social Care Trust, Lisburn Road, Belfast, UK; Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Jubilee Road, Belfast, UK
| | - Karl T Butterworth
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Jubilee Road, Belfast, UK
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11
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Pedersen LN, Valenzuela Ripoll C, Ozcan M, Guo Z, Lotfinaghsh A, Zhang S, Ng S, Weinheimer C, Nigro J, Kovacs A, Diab A, Klaas A, Grogan F, Cho Y, Ataran A, Luehmann H, Heck A, Kolb K, Strong L, Navara R, Walls GM, Hugo G, Samson P, Cooper D, Reynoso FJ, Schwarz JK, Moore K, Lavine K, Rentschler SL, Liu Y, Woodard PK, Robinson C, Cuculich PS, Bergom C, Javaheri A. Cardiac radiation improves ventricular function in mice and humans with cardiomyopathy. MED 2023; 4:928-943.e5. [PMID: 38029754 PMCID: PMC10994563 DOI: 10.1016/j.medj.2023.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 08/30/2023] [Accepted: 10/30/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Rapidly dividing cells are more sensitive to radiation therapy (RT) than quiescent cells. In the failing myocardium, macrophages and fibroblasts mediate collateral tissue injury, leading to progressive myocardial remodeling, fibrosis, and pump failure. Because these cells divide more rapidly than cardiomyocytes, we hypothesized that macrophages and fibroblasts would be more susceptible to lower doses of radiation and that cardiac radiation could therefore attenuate myocardial remodeling. METHODS In three independent murine heart failure models, including models of metabolic stress, ischemia, and pressure overload, mice underwent 5 Gy cardiac radiation or sham treatment followed by echocardiography. Immunofluorescence, flow cytometry, and non-invasive PET imaging were employed to evaluate cardiac macrophages and fibroblasts. Serial cardiac magnetic resonance imaging (cMRI) from patients with cardiomyopathy treated with 25 Gy cardiac RT for ventricular tachycardia (VT) was evaluated to determine changes in cardiac function. FINDINGS In murine heart failure models, cardiac radiation significantly increased LV ejection fraction and reduced end-diastolic volume vs. sham. Radiation resulted in reduced mRNA abundance of B-type natriuretic peptide and fibrotic genes, and histological assessment of the LV showed reduced fibrosis. PET and flow cytometry demonstrated reductions in pro-inflammatory macrophages, and immunofluorescence demonstrated reduced proliferation of macrophages and fibroblasts with RT. In patients who were treated with RT for VT, cMRI demonstrated decreases in LV end-diastolic volume and improvements in LV ejection fraction early after treatment. CONCLUSIONS These results suggest that 5 Gy cardiac radiation attenuates cardiac remodeling in mice and humans with heart failure. FUNDING NIH, ASTRO, AHA, Longer Life Foundation.
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Affiliation(s)
- Lauren N Pedersen
- Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | | | - Mualla Ozcan
- Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Zhen Guo
- Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Aynaz Lotfinaghsh
- Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Shiyang Zhang
- Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Sherwin Ng
- Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Carla Weinheimer
- Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Jessica Nigro
- Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Attila Kovacs
- Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Ahmed Diab
- Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Amanda Klaas
- Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Felicia Grogan
- Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Yoonje Cho
- Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Anahita Ataran
- Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Hannah Luehmann
- Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Abigail Heck
- Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Kollin Kolb
- Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Lori Strong
- Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Rachita Navara
- Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Gerard M Walls
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Belfast BT97AE, Northern Ireland
| | - Geoff Hugo
- Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Pamela Samson
- Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Daniel Cooper
- Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Francisco J Reynoso
- Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Julie K Schwarz
- Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Kaitlin Moore
- Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Kory Lavine
- Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Stacey L Rentschler
- Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Yongjian Liu
- Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Pamela K Woodard
- Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Clifford Robinson
- Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Phillip S Cuculich
- Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Carmen Bergom
- Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA.
| | - Ali Javaheri
- Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA; John J. Cochran Veterans Affairs Medical Center, St. Louis, MO 63106, USA.
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12
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van der Ree MH, Hoeksema WF, Luca A, Visser J, Balgobind BV, Zumbrink M, Spier R, Herrera-Siklody C, Lee J, Bates M, Daniel J, Peedell C, Boda-Heggemann J, Rudic B, Merten R, Dieleman EM, Rinaldi CA, Ahmad S, Whitaker J, Bhagirath P, Hatton MQ, Riley S, Grehn M, Schiappacasse L, Blanck O, Hohmann S, Pruvot E, Postema PG. Stereotactic arrhythmia radioablation: A multicenter pre-post intervention safety evaluation of the implantable cardioverter-defibrillator function. Radiother Oncol 2023; 189:109910. [PMID: 37709052 DOI: 10.1016/j.radonc.2023.109910] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 09/08/2023] [Accepted: 09/08/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND Stereotactic arrhythmia radioablation (STAR) appears to be beneficial in selected patients with therapy-refractory ventricular tachycardia (VT). However, high-dose radiotherapy used for STAR-treatment may affect functioning of the patients' implantable cardioverter defibrillator (ICD) by direct effects of radiation on ICD components or cardiac tissue. Currently, the effect of STAR on ICD functioning remains unknown. METHODS A retrospective pre-post multicenter study evaluating ICD functioning in the 12-month before and after STAR was performed. Patients with (non)ischemic cardiomyopathies with therapy-refractory VT and ICD who underwent STAR were included and the occurrence of ICD-related adverse events was collected. Evaluated ICD parameters included sensing, capture threshold and impedance. A linear mixed-effects model was used to investigate the association between STAR, radiotherapy dose and changes in lead parameters over time. RESULTS In total, 43 patients (88% male) were included in this study. All patients had an ICD with an additional right atrial lead in 34 (79%) and a ventricular lead in 17 (40%) patients. Median ICD-generator dose was 0.1 Gy and lead tip dose ranged from 0-32 Gy. In one patient (2%), a reset occurred during treatment, but otherwise, STAR and radiotherapy dose were not associated with clinically relevant alterations in ICD leads parameters. CONCLUSIONS STAR treatment did not result in major ICD malfunction. Only one radiotherapy related adverse event occurred during the study follow-up without patient harm. No clinically relevant alterations in ICD functioning were observed after STAR in any of the leads. With the reported doses STAR appears to be safe.
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Affiliation(s)
- Martijn H van der Ree
- Amsterdam UMC location University of Amsterdam, Department of Cardiology, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Amsterdam, the Netherlands; Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Wiert F Hoeksema
- Amsterdam UMC location University of Amsterdam, Department of Cardiology, Meibergdreef 9, Amsterdam, the Netherlands
| | - Adrian Luca
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Jorrit Visser
- Amsterdam UMC location University of Amsterdam, Department of Radiation Oncology, Meibergdreef 9, Amsterdam, The Netherlands
| | - Brian V Balgobind
- Amsterdam UMC location University of Amsterdam, Department of Radiation Oncology, Meibergdreef 9, Amsterdam, The Netherlands
| | - Michiel Zumbrink
- Amsterdam UMC location University of Amsterdam, Department of Cardiology, Meibergdreef 9, Amsterdam, the Netherlands
| | - Raymond Spier
- Amsterdam UMC location University of Amsterdam, Department of Cardiology, Meibergdreef 9, Amsterdam, the Netherlands
| | | | - Justin Lee
- Department of Cardiology, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - Matthew Bates
- Department of Cardiology, South Tees Hospitals NHS Foundation Trust, Middleborough, UK
| | - Jim Daniel
- Department of Radiation Oncology, South Tees Hospitals NHS Foundation Trust, Middlesborough, UK
| | - Clive Peedell
- Department of Radiation Oncology, South Tees Hospitals NHS Foundation Trust, Middlesborough, UK
| | - Judit Boda-Heggemann
- Department of Radiation Oncology, University Medical Center Mannheim University of Heidelberg, Mannheim, Germany
| | - Boris Rudic
- Department of Cardiology, University Medical Center Mannheim University of Heidelberg, Mannheim, Germany
| | - Roland Merten
- Department of Radiation Oncology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Edith M Dieleman
- Amsterdam UMC location University of Amsterdam, Department of Radiation Oncology, Meibergdreef 9, Amsterdam, The Netherlands
| | - Cristopher A Rinaldi
- Department of Cardiology, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Shahreen Ahmad
- Department of Radiation Oncology, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - John Whitaker
- Department of Cardiology, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Pranav Bhagirath
- Amsterdam UMC location University of Amsterdam, Department of Cardiology, Meibergdreef 9, Amsterdam, the Netherlands; Department of Cardiology, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Matthew Q Hatton
- Department of Clinical Oncology, Weston Park Hospital, Sheffield, UK
| | - Stephen Riley
- Department of Clinical Oncology, Weston Park Hospital, Sheffield, UK
| | - Melanie Grehn
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Luis Schiappacasse
- Department of Radiation Oncology, Lausanne University Hospital, Lausanne, Switzerland
| | - Oliver Blanck
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Stephan Hohmann
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Etienne Pruvot
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Pieter G Postema
- Amsterdam UMC location University of Amsterdam, Department of Cardiology, Meibergdreef 9, Amsterdam, the Netherlands.
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13
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Puvanasunthararajah S, Camps SM, Wille ML, Fontanarosa D. Deep learning-based ultrasound transducer induced CT metal artifact reduction using generative adversarial networks for ultrasound-guided cardiac radioablation. Phys Eng Sci Med 2023; 46:1399-1410. [PMID: 37548887 DOI: 10.1007/s13246-023-01307-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 07/20/2023] [Indexed: 08/08/2023]
Abstract
In US-guided cardiac radioablation, a possible workflow includes simultaneous US and planning CT acquisitions, which can result in US transducer-induced metal artifacts on the planning CT scans. To reduce the impact of these artifacts, a metal artifact reduction (MAR) algorithm has been developed based on a deep learning Generative Adversarial Network called Cycle-MAR, and compared with iMAR (Siemens), O-MAR (Philips) and MDT (ReVision Radiology), and CCS-MAR (Combined Clustered Scan-based MAR). Cycle-MAR was trained with a supervised learning scheme using sets of paired clinical CT scans with and without simulated artifacts. It was then evaluated on CT scans with real artifacts of an anthropomorphic phantom, and on sets of clinical CT scans with simulated artifacts which were not used for Cycle-MAR training. Image quality metrics and HU value-based analysis were used to evaluate the performance of Cycle-MAR compared to the other algorithms. The proposed Cycle-MAR network effectively reduces the negative impact of the metal artifacts. For example, the calculated HU value improvement percentage for the cardiac structures in the clinical CT scans was 59.58%, 62.22%, and 72.84% after MDT, CCS-MAR, and Cycle-MAR application, respectively. The application of MAR algorithms reduces the impact of US transducer-induced metal artifacts on CT scans. In comparison to iMAR, O-MAR, MDT, and CCS-MAR, the application of developed Cycle-MAR network on CT scans performs better in reducing these metal artifacts.
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Affiliation(s)
- Sathyathas Puvanasunthararajah
- School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD, Australia.
- Centre for Biomedical Technologies, Queensland University of Technology, Brisbane, QLD, Australia.
| | | | - Marie-Luise Wille
- Centre for Biomedical Technologies, Queensland University of Technology, Brisbane, QLD, Australia
- School of Mechanical, Medical & Process Engineering, Faculty of Engineering, Queensland University of Technology, Brisbane, QLD, Australia
- ARC ITTC for Multiscale 3D Imaging, Modelling, and Manufacturing, Queensland University of Technology, Brisbane, QLD, Australia
| | - Davide Fontanarosa
- School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD, Australia
- Centre for Biomedical Technologies, Queensland University of Technology, Brisbane, QLD, Australia
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14
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Balgobind BV, Visser J, Grehn M, Marquard Knap M, de Ruysscher D, Levis M, Alcantara P, Boda-Heggemann J, Both M, Cozzi S, Cvek J, Dieleman EMT, Elicin O, Giaj-Levra N, Jumeau R, Krug D, Algara López M, Mayinger M, Mehrhof F, Miszczyk M, Pérez-Calatayud MJ, van der Pol LHG, van der Toorn PP, Vitolo V, Postema PG, Pruvot E, Verhoeff JC, Blanck O. Refining critical structure contouring in STereotactic Arrhythmia Radioablation (STAR): Benchmark results and consensus guidelines from the STOPSTORM.eu consortium. Radiother Oncol 2023; 189:109949. [PMID: 37827279 DOI: 10.1016/j.radonc.2023.109949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 09/05/2023] [Accepted: 10/09/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND AND PURPOSE In patients with recurrent ventricular tachycardia (VT), STereotactic Arrhythmia Radioablation (STAR) shows promising results. The STOPSTORM.eu consortium was established to investigate and harmonise STAR treatment in Europe. The primary goals of this benchmark study were to standardise contouring of organs at risk (OAR) for STAR, including detailed substructures of the heart, and accredit each participating centre. MATERIALS AND METHODS Centres within the STOPSTORM.eu consortium were asked to delineate 31 OAR in three STAR cases. Delineation was reviewed by the consortium expert panel and after a dedicated workshop feedback and accreditation was provided to all participants. Further quantitative analysis was performed by calculating DICE similarity coefficients (DSC), median distance to agreement (MDA), and 95th percentile distance to agreement (HD95). RESULTS Twenty centres participated in this study. Based on DSC, MDA and HD95, the delineations of well-known OAR in radiotherapy were similar, such as lungs (median DSC = 0.96, median MDA = 0.1 mm and median HD95 = 1.1 mm) and aorta (median DSC = 0.90, median MDA = 0.1 mm and median HD95 = 1.5 mm). Some centres did not include the gastro-oesophageal junction, leading to differences in stomach and oesophagus delineations. For cardiac substructures, such as chambers (median DSC = 0.83, median MDA = 0.2 mm and median HD95 = 0.5 mm), valves (median DSC = 0.16, median MDA = 4.6 mm and median HD95 = 16.0 mm), coronary arteries (median DSC = 0.4, median MDA = 0.7 mm and median HD95 = 8.3 mm) and the sinoatrial and atrioventricular nodes (median DSC = 0.29, median MDA = 4.4 mm and median HD95 = 11.4 mm), deviations between centres occurred more frequently. After the dedicated workshop all centres were accredited and contouring consensus guidelines for STAR were established. CONCLUSION This STOPSTORM multi-centre critical structure contouring benchmark study showed high agreement for standard radiotherapy OAR. However, for cardiac substructures larger disagreement in contouring occurred, which may have significant impact on STAR treatment planning and dosimetry evaluation. To standardize OAR contouring, consensus guidelines for critical structure contouring in STAR were established.
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Affiliation(s)
- Brian V Balgobind
- Department of Radiation Oncology, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands.
| | - Jorrit Visser
- Department of Radiation Oncology, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
| | - Melanie Grehn
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | | | - Dirk de Ruysscher
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University, Maastricht, the Netherlands
| | - Mario Levis
- Department of Oncology, University of Torino, Torino, Italy
| | - Pino Alcantara
- Department of Radiation Oncology, Hospital Clínico San Carlos, Faculty of Medicine, University Complutense of Madrid, Madrid, Spain
| | - Judit Boda-Heggemann
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Marcus Both
- Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Salvatore Cozzi
- Radiation Oncology Unit, Azienda USL-IRCCS, Reggio Emilia, Italy; Radiation Oncology Department, Centre Léon Bérard, Lyon, France
| | - Jakub Cvek
- Department of Oncology, University Hospital and Faculty of Medicine, Ostrava, Czech Republic
| | - Edith M T Dieleman
- Department of Radiation Oncology, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
| | - Olgun Elicin
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Niccolò Giaj-Levra
- Department of Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy
| | - Raphaël Jumeau
- Department of Radio-Oncology, Lausanne University Hospital, Lausanne, Switzerland
| | - David Krug
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Manuel Algara López
- Department of Radiotherapy, Hospital del Mar, Universitat Pompeu Fabra, Barcelona, Spain
| | - Michael Mayinger
- Department of Radiation Oncology, University Hospital of Zurich, Zurich, Switzerland
| | - Felix Mehrhof
- Department for Radiation Oncology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Marcin Miszczyk
- IIIrd Radiotherapy and Chemotherapy Department, Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice, Poland
| | | | - Luuk H G van der Pol
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Viviana Vitolo
- Radiation Oncology Clinical Department, National Center of Oncological Hadrontherapy (Fondazione CNAO), Pavia, Italy
| | - Pieter G Postema
- Department of Cardiology, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
| | - Etienne Pruvot
- Heart and Vessel Department, Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Joost C Verhoeff
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Oliver Blanck
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
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15
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Stevens RRF, Hazelaar C, Fast MF, Mandija S, Grehn M, Cvek J, Knybel L, Dvorak P, Pruvot E, Verhoeff JJC, Blanck O, van Elmpt W. Stereotactic Arrhythmia Radioablation (STAR): Assessment of cardiac and respiratory heart motion in ventricular tachycardia patients - A STOPSTORM.eu consortium review. Radiother Oncol 2023; 188:109844. [PMID: 37543057 DOI: 10.1016/j.radonc.2023.109844] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 07/10/2023] [Accepted: 07/28/2023] [Indexed: 08/07/2023]
Abstract
AIM To identify the optimal STereotactic Arrhythmia Radioablation (STAR) strategy for individual patients, cardiorespiratory motion of the target volume in combination with different treatment methodologies needs to be evaluated. However, an authoritative overview of the amount of cardiorespiratory motion in ventricular tachycardia (VT) patients is missing. METHODS In this STOPSTORM consortium study, we performed a literature review to gain insight into cardiorespiratory motion of target volumes for STAR. Motion data and target volumes were extracted and summarized. RESULTS Out of the 232 studies screened, 56 provided data on cardiorespiratory motion, of which 8 provided motion amplitudes in VT patients (n = 94) and 10 described (cardiac/cardiorespiratory) internal target volumes (ITVs) obtained in VT patients (n = 59). Average cardiac motion of target volumes was < 5 mm in all directions, with maximum values of 8.0, 5.2 and 6.5 mm in Superior-Inferior (SI), Left-Right (LR), Anterior-Posterior (AP) direction, respectively. Cardiorespiratory motion of cardiac (sub)structures showed average motion between 5-8 mm in the SI direction, whereas, LR and AP motions were comparable to the cardiac motion of the target volumes. Cardiorespiratory ITVs were on average 120-284% of the gross target volume. Healthy subjects showed average cardiorespiratory motion of 10-17 mm in SI and 2.4-7 mm in the AP direction. CONCLUSION This review suggests that despite growing numbers of patients being treated, detailed data on cardiorespiratory motion for STAR is still limited. Moreover, data comparison between studies is difficult due to inconsistency in parameters reported. Cardiorespiratory motion is highly patient-specific even under motion-compensation techniques. Therefore, individual motion management strategies during imaging, planning, and treatment for STAR are highly recommended.
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Affiliation(s)
- Raoul R F Stevens
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, the Netherlands.
| | - Colien Hazelaar
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Martin F Fast
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Stefano Mandija
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Melanie Grehn
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Jakub Cvek
- Department of Oncology, University Hospital and Faculty of Medicine, Ostrava, Czech Republic
| | - Lukas Knybel
- Department of Oncology, University Hospital and Faculty of Medicine, Ostrava, Czech Republic
| | - Pavel Dvorak
- Department of Oncology, University Hospital and Faculty of Medicine, Ostrava, Czech Republic
| | - Etienne Pruvot
- Heart and Vessel Department, Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Joost J C Verhoeff
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Oliver Blanck
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Wouter van Elmpt
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, the Netherlands
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16
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Wang H, Barbhaiya CR, Yuan Y, Barbee D, Chen T, Axel L, Chinitz LA, Evans AJ, Byun DJ. A Tool to Integrate Electrophysiological Mapping for Cardiac Radioablation of Ventricular Tachycardia. Adv Radiat Oncol 2023; 8:101272. [PMID: 37415904 PMCID: PMC10320498 DOI: 10.1016/j.adro.2023.101272] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 05/08/2023] [Indexed: 07/08/2023] Open
Abstract
Purpose Cardiac radioablation is an emerging therapy for recurrent ventricular tachycardia. Electrophysiology (EP) data, including electroanatomic maps (EAM) and electrocardiographic imaging (ECGI), provide crucial information for defining the arrhythmogenic target volume. The absence of standardized workflows and software tools to integrate the EP maps into a radiation planning system limits their use. This study developed a comprehensive software tool to enable efficient utilization of the mapping for cardiac radioablation treatment planning. Methods and Materials The tool, HeaRTmap, is a Python-scripted plug-in module on the open-source 3D Slicer software platform. HeaRTmap is able to import EAM and ECGI data and visualize the maps in 3D Slicer. The EAM is translated into a 3D space by registration with cardiac magnetic resonance images (MRI) or computed tomography (CT). After the scar area is outlined on the mapping surface, the tool extracts and extends the annotated patch into a closed surface and converts it into a structure set associated with the anatomic images. The tool then exports the structure set and the images as The Digital Imaging and Communications in Medicine Standard in Radiotherapy for a radiation treatment planning system to import. Overlapping the scar structure on simulation CT, a transmural target volume is delineated for treatment planning. Results The tool has been used to transfer Ensite NavX EAM data into the Varian Eclipse treatment planning system in radioablation on 2 patients with ventricular tachycardia. The ECGI data from CardioInsight was retrospectively evaluated using the tool to derive the target volume for a patient with left ventricular assist device, showing volumetric matching with the clinically used target with a Dice coefficient of 0.71. Conclusions HeaRTmap smoothly fuses EP information from different mapping systems with simulation CT for accurate definition of radiation target volume. The efficient integration of EP data into treatment planning potentially facilitates the study and adoption of the technique.
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Affiliation(s)
- Hesheng Wang
- Department of Radiation Oncology, New York University Grossman School of Medicine, New York, New York
| | - Chirag R. Barbhaiya
- Department of Medicine, New York University Grossman School of Medicine, New York, New York
| | - Ye Yuan
- Atropos Health, Palo Alto, California
| | - David Barbee
- Department of Radiation Oncology, New York University Grossman School of Medicine, New York, New York
| | - Ting Chen
- Department of Radiation Oncology, New York University Grossman School of Medicine, New York, New York
| | - Leon Axel
- Department of Medicine, New York University Grossman School of Medicine, New York, New York
- Department of Radiology, New York University Grossman School of Medicine, New York, New York
| | - Larry A. Chinitz
- Department of Medicine, New York University Grossman School of Medicine, New York, New York
| | - Andrew J. Evans
- Department of Radiation Oncology, New York University Grossman School of Medicine, New York, New York
| | - David J. Byun
- Department of Radiation Oncology, New York University Grossman School of Medicine, New York, New York
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17
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Fast MF, Lydiard S, Boda-Heggemann J, Tanadini-Lang S, Muren LP, Clark CH, Blanck O. Precision requirements in stereotactic arrhythmia radioablation for ventricular tachycardia. Phys Imaging Radiat Oncol 2023; 28:100508. [PMID: 38026083 PMCID: PMC10679852 DOI: 10.1016/j.phro.2023.100508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Affiliation(s)
- Martin F Fast
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Judit Boda-Heggemann
- Department of Radiation Oncology, University Medicine Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- DKFZ Hector Cancer Institute at the University Medical Center Mannheim, Germany
| | - Stephanie Tanadini-Lang
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Switzerland
| | - Ludvig P Muren
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Catharine H Clark
- Radiotherapy Physics, University College London Hospital, 250 Euston Rd, London NW1 2PG, UK
- Department of Medical Physics and Bioengineering, University College London, Malet Place, London WC1E 6BT, UK
- Medical Physics Dept, National Physical Laboratory, Hampton Rd, London TW11 0PX, UK
| | - Oliver Blanck
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Arnold-Heller-Strasse 3, Kiel 24105, Germany
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18
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Krug D, Zaman A, Eidinger L, Grehn M, Boda-Heggemann J, Rudic B, Mehrhof F, Boldt LH, Hohmann S, Merten R, Buergy D, Fleckenstein J, Kluge A, Rogge A, Both M, Rades D, Tilz RR, Olbrich D, König IR, Siebert FA, Schweikard A, Vonthein R, Bonnemeier H, Dunst J, Blanck O. Radiosurgery for ventricular tachycardia (RAVENTA): interim analysis of a multicenter multiplatform feasibility trial. Strahlenther Onkol 2023:10.1007/s00066-023-02091-9. [PMID: 37285038 DOI: 10.1007/s00066-023-02091-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 04/23/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND Single-session cardiac stereotactic radiation therapy (SBRT) has demonstrated promising results for patients with refractory ventricular tachycardia (VT). However, the full safety profile of this novel treatment remains unknown and very limited data from prospective clinical multicenter trials are available. METHODS The prospective multicenter multiplatform RAVENTA (radiosurgery for ventricular tachycardia) study assesses high-precision image-guided cardiac SBRT with 25 Gy delivered to the VT substrate determined by high-definition endocardial and/or epicardial electrophysiological mapping in patients with refractory VT ineligible for catheter ablation and an implanted cardioverter defibrillator (ICD). Primary endpoint is the feasibility of full-dose application and procedural safety (defined as an incidence of serious [grade ≥ 3] treatment-related complications ≤ 5% within 30 days after therapy). Secondary endpoints comprise VT burden, ICD interventions, treatment-related toxicity, and quality of life. We present the results of a protocol-defined interim analysis. RESULTS Between 10/2019 and 12/2021, a total of five patients were included at three university medical centers. In all cases, the treatment was carried out without complications. There were no serious potentially treatment-related adverse events and no deterioration of left ventricular ejection fraction upon echocardiography. Three patients had a decrease in VT episodes during follow-up. One patient underwent subsequent catheter ablation for a new VT with different morphology. One patient with local VT recurrence died 6 weeks after treatment in cardiogenic shock. CONCLUSION The interim analysis of the RAVENTA trial demonstrates early initial feasibility of this new treatment without serious complications within 30 days after treatment in five patients. Recruitment will continue as planned and the study has been expanded to further university medical centers. TRIAL REGISTRATION NUMBER NCT03867747 (clinicaltrials.gov). Registered March 8, 2019. Study start: October 1, 2019.
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Affiliation(s)
- David Krug
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus L, 24105, Kiel, Germany.
| | - Adrian Zaman
- Klinik für Innere Medizin III, Kardiologie, Abteilung für Elektrophysiologie und Rhythmologie, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Lina Eidinger
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus L, 24105, Kiel, Germany
- Klinik für Innere Medizin III, Kardiologie, Abteilung für Elektrophysiologie und Rhythmologie, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Melanie Grehn
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus L, 24105, Kiel, Germany
| | - Judit Boda-Heggemann
- Universitätsmedizin Mannheim, Klinik für Strahlentherapie und Radioonkologie, Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Germany
| | - Boris Rudic
- Universitätsmedizin Mannheim, Medizinische Klinik I, Abteilung für Elektrophysiologie und Rhythmologie, Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Germany
| | - Felix Mehrhof
- Klinik für Radioonkologie und Strahlentherapie, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Leif-Hendrik Boldt
- Medizinische Klinik mit Schwerpunkt Kardiologie (CVK), Abteilung für Elektrophysiologie und Rhythmologie, Charité Universitätsmedizin Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Stephan Hohmann
- Hannover Herzrhythmus Centrum, Klinik für Kardiologie und Angiologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Roland Merten
- Klinik für Strahlentherapie und Spezielle Onkologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Daniel Buergy
- Universitätsmedizin Mannheim, Klinik für Strahlentherapie und Radioonkologie, Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Germany
| | - Jens Fleckenstein
- Universitätsmedizin Mannheim, Klinik für Strahlentherapie und Radioonkologie, Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Germany
| | - Anne Kluge
- Klinik für Radioonkologie und Strahlentherapie, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Annette Rogge
- Klinisches Ethikkomitee, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Marcus Both
- Klinik für Radiologie und Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Dirk Rades
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - Roland Richard Tilz
- Klinik für Rhythmologie, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - Denise Olbrich
- Zentrum für Klinische Studien, Universität zu Lübeck, Lübeck, Germany
| | - Inke R König
- Institut für Medizinische Biometrie und Statistik, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - Frank-Andre Siebert
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus L, 24105, Kiel, Germany
| | - Achim Schweikard
- Institut für Robotik und Kognitive Systeme, Universität zu Lübeck, Lübeck, Germany
| | - Reinhard Vonthein
- Institut für Medizinische Biometrie und Statistik, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - Hendrik Bonnemeier
- Klinik für Innere Medizin III, Kardiologie, Abteilung für Elektrophysiologie und Rhythmologie, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
- Klinik für Kardiologie, Helios Klinik Cuxhaven, Cuxhaven, Germany
| | - Jürgen Dunst
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus L, 24105, Kiel, Germany
| | - Oliver Blanck
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus L, 24105, Kiel, Germany
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19
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Harms J, Schreibmann E, Mccall NS, Lloyd MS, Higgins KA, Castillo R. Cardiac motion and its dosimetric impact during radioablation for refractory ventricular tachycardia. J Appl Clin Med Phys 2023:e13925. [PMID: 36747376 DOI: 10.1002/acm2.13925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 12/09/2022] [Accepted: 01/19/2023] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION Cardiac radioablation (CR) is a noninvasive treatment option for patients with refractory ventricular tachycardia (VT) during which high doses of radiation, typically 25 Gy, are delivered to myocardial scar. In this study, we investigate motion from cardiac cycle and evaluate the dosimetric impact in a cohort of patients treated with CR. METHODS This retrospective study included eight patients treated at our institution who had respiratory-correlated and ECG-gated 4DCT scans acquired within 2 weeks of CR. Deformable image registration was applied between maximum systole (SYS) and diastole (DIAS) CTs to assess cardiac motion. The average respiratory-correlated CT (AVGresp ) was deformably registered to the average cardiac (AVGcardiac ), SYS, and DIAS CTs, and contours were propagated using the deformation vector fields (DVFs). Finally, the original treatment plan was recalculated on the deformed AVGresp CT for dosimetric assessment. RESULTS Motion magnitudes were measured as the mean (SD) value over the DVFs within each structure. Displacement during the cardiac cycle for all chambers was 1.4 (0.9) mm medially/laterally (ML), 1.6 (1.0) mm anteriorly/posteriorly (AP), and 3.0 (2.8) mm superiorly/inferiorly (SI). Displacement for the 12 distinct clinical target volumes (CTVs) was 1.7 (1.5) mm ML, 2.4 (1.1) mm AP, and 2.1 (1.5) SI. Displacements between the AVGresp and AVGcardiac scans were 4.2 (2.0) mm SI and 5.8 (1.4) mm total. Dose recalculations showed that cardiac motion may impact dosimetry, with dose to 95% of the CTV dropping from 27.0 (1.3) Gy on the AVGresp to 20.5 (7.1) Gy as estimated on the AVGcardiac . CONCLUSIONS Cardiac CTV motion in this patient cohort is on average below 3 mm, location-dependent, and when not accounted for in treatment planning may impact target coverage. Further study is needed to assess the impact of cardiac motion on clinical outcomes.
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Affiliation(s)
- Joseph Harms
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Eduard Schreibmann
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Neal S Mccall
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Michael S Lloyd
- Section of Clinical Cardiac Electrophysiology, Emory University, Atlanta, Georgia, USA
| | - Kristin A Higgins
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Richard Castillo
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
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20
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Aras D, Çetin EHÖ, Ozturk HF, Ozdemir E, Kara M, Ekizler FA, Ozeke O, Ozcan F, Korkmaz A, Kervan U, Turhan N, Coskun N, Tezcan Y, Huang H, Aksu T, Topaloglu S. Stereotactic body radioablation therapy as an immediate and early term antiarrhythmic palliative therapeutic choice in patients with refractory ventricular tachycardia. J Interv Card Electrophysiol 2023; 66:135-143. [PMID: 36040658 PMCID: PMC9424800 DOI: 10.1007/s10840-022-01352-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 08/16/2022] [Indexed: 10/27/2022]
Abstract
BACKGROUND Stereotactic body radioablation therapy (SBRT) has recently been introduced with the ability to provide ablative energy noninvasively to arrhythmogenic substrate while reducing damage to normal cardiac tissue nearby and minimizing patients' procedural risk. There is still debate regarding whether SBRT has a predominant effect in the early or late period after the procedure. We sought to assess the time course of SBRT's efficacy as well as the value of using a blanking period following a SBRT session. METHODS Eight patients (mean age 58 ± 14 years) underwent eight SBRT sessions for refractory ventricular tachycardia (VT). SBRT was given using a linear accelerator device with a total dose of 25 Gy to the targeted area. RESULTS During a median follow-up of 8 months, all patients demonstrated VT recurrences; however, implantable cardioverter-defibrillator (ICD) and anti-tachycardia pacing therapies were significantly reduced with SBRT (8.46 to 0.83/per month, p = 0.047; 18.50 to 3.29/per month, p = 0.036, respectively). While analyzing the temporal SBRT outcomes, the 2 weeks to 3 months period demonstrated the most favorable outcomes. After 6 months, one patient was ICD therapy-free and the remaining patients demonstrated VT episodes. CONCLUSIONS Our findings showed that the SBRT was associated with a marked reduction in the burden of VT and ICD interventions especially during first 3 months. Although SBRT does not seem to succeed complete termination of VT in long-term period, our findings support the strategy that SBRT can be utilized for immediate antiarrhythmic palliation in critically ill patients with otherwise untreatable refractory VT and electrical storm.
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Affiliation(s)
- Dursun Aras
- grid.411781.a0000 0004 0471 9346Department of Cardiology, Istanbul Medipol University, Istanbul, Turkey
| | - Elif Hande Özcan Çetin
- Department of Cardiology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Huseyin Furkan Ozturk
- grid.449874.20000 0004 0454 9762Department of Radiation Oncology, Ankara Yildirim Beyazit University, Ankara City Hospital, Ankara, Turkey
| | - Elif Ozdemir
- grid.449874.20000 0004 0454 9762Department of Nuclear Medicine, Ankara Yildirim Beyazit University, Ankara City Hospital, Ankara, Turkey
| | - Meryem Kara
- Department of Cardiology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Firdevs Aysenur Ekizler
- Department of Cardiology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Ozcan Ozeke
- Department of Cardiology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Firat Ozcan
- Department of Cardiology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Ahmet Korkmaz
- Department of Cardiology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Umit Kervan
- Department of Cardiovascular Surgery, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Nesrin Turhan
- Department of Pathology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Nazim Coskun
- Department of Nuclear Medicine, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Yilmaz Tezcan
- grid.449874.20000 0004 0454 9762Department of Radiation Oncology, Ankara Yildirim Beyazit University, Ankara City Hospital, Ankara, Turkey
| | - Henry Huang
- grid.262743.60000000107058297Department of Cardiology, Rush Medical College, Chicago, IL USA
| | - Tolga Aksu
- Department of Cardiology, Yeditepe University Istanbul, Istanbul, Turkey, 34100.
| | - Serkan Topaloglu
- Department of Cardiology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
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21
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Reis CQM, Robar JL. Evaluation of the feasibility of cardiac gating for SBRT of ventricular tachycardia based on real-time ECG signal acquisition. J Appl Clin Med Phys 2022; 24:e13814. [PMID: 36286619 PMCID: PMC9924123 DOI: 10.1002/acm2.13814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 09/10/2022] [Accepted: 09/30/2022] [Indexed: 11/08/2022] Open
Abstract
PURPOSE To investigate the feasibility of cardiac synchronized gating in stereotactic body radiation therapy (SBRT) of ventricular tachycardia (VT) using a real-time electrocardiogram (ECG) signal acquisition. METHODS AND MATERIALS Stability of beam characteristics during simulated ECG gating was examined by developing a microcontroller interface to a Varian Clinac iX linear accelerator allowing gating at frequencies and duty cycles relevant to cardiac rhythm. Delivery accuracy was evaluated by measuring dose linearity with an ionization chamber, and flatness and symmetry with a two-dimensional detector array, for different gating windows within typical human cardiac cycle periods. To establish a practical method of gating based on actual ECG signals, an AD8232 Heart Monitor board was used to acquire the ECG signal and synchronize the beam delivery. Real-time cardiac gated delivery measurements were performed for a single 10 × 10 cm2 field and for a VT-SBRT plan using intensity-modulated radiation therapy (IMRT). RESULTS AND DISCUSSION Dose per monitor unit (MU) values were found to be linear within most gating windows investigated with maximum differences relative to non-gated delivery of <2% for gating windows ≥200 ms and for >10 MUs. Beam profiles for both gated and non-gated modes were also found to agree with maximum differences of 0.5% relative to central axis dose for all sets of beam-on/beam-off combinations. Comparison of dose distributions for intensity-modulated SBRT plans between non-gating and cardiac gating modes provided a gamma passing rate of 97.2% for a 2% 2 mm tolerance. CONCLUSIONS Beam output is stable with respect to linearity, flatness, and symmetry for gating windows within cardiac cycle periods. Agreement between dose distributions for VT-SBRT using IMRT in non-gated and cardiac cycle gated delivery modes shows that the proposed methodology is feasible. Technically, gating for delivery of SBRT for VT is possible with regard to beam stability.
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Affiliation(s)
- Cristiano Q. M. Reis
- Department of Radiation OncologyDalhousie UniversityHalifaxNova ScotiaCanada,Department of Medical PhysicsNova Scotia HealthHalifaxNova ScotiaCanada,Department of Physics and Atmospheric ScienceDalhousie UniversityHalifaxNova ScotiaCanada
| | - James L. Robar
- Department of Radiation OncologyDalhousie UniversityHalifaxNova ScotiaCanada,Department of Medical PhysicsNova Scotia HealthHalifaxNova ScotiaCanada,Department of Physics and Atmospheric ScienceDalhousie UniversityHalifaxNova ScotiaCanada
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22
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Walls GM, O'Kane R, Ghita M, Kuburas R, McGarry CK, Cole AJ, Jain S, Butterworth KT. Murine models of radiation cardiotoxicity: A systematic review and recommendations for future studies. Radiother Oncol 2022; 173:19-31. [PMID: 35533784 DOI: 10.1016/j.radonc.2022.04.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 04/13/2022] [Accepted: 04/29/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE The effects of radiation on the heart are dependent on dose, fractionation, overall treatment time, and pre-existing cardiovascular pathology. Murine models have played a central role in improving our understanding of the radiation response of the heart yet a wide range of exposure parameters have been used. We evaluated the study design of published murine cardiac irradiation experiments to assess gaps in the literature and to suggest guidance for the harmonisation of future study reporting. METHODS AND MATERIALS A systematic review of mouse/rat studies published 1981-2021 that examined the effect of radiation on the heart was performed. The protocol was published on PROSPERO (CRD42021238921) and the findings were reported in accordance with the PRISMA guidance. Risk of bias was assessed using the SYRCLE checklist. RESULTS 159 relevant full-text original articles were reviewed. The heart only was the target volume in 67% of the studies and simulation details were unavailable for 44% studies. Dosimetry methods were reported in 31% studies. The pulmonary effects of whole and partial heart irradiation were reported in 13% studies. Seventy-eight unique dose-fractionation schedules were evaluated. Large heterogeneity was observed in the endpoints measured, and the reporting standards were highly variable. CONCLUSIONS Current murine models of radiation cardiotoxicity cover a wide range of irradiation configurations and latency periods. There is a lack of evidence describing clinically relevant dose-fractionations, circulating biomarkers and radioprotectants. Recommendations for the consistent reporting of methods and results of in vivo cardiac irradiation studies are made to increase their suitability for informing the design of clinical studies.
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Affiliation(s)
- Gerard M Walls
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Lisburn Road, Belfast, Northern Ireland; Cancer Centre Belfast City Hospital, Belfast Health & Social Care Trust, Lisburn Road, Belfast, Northern Ireland.
| | - Reagan O'Kane
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Lisburn Road, Belfast, Northern Ireland
| | - Mihaela Ghita
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Lisburn Road, Belfast, Northern Ireland
| | - Refik Kuburas
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Lisburn Road, Belfast, Northern Ireland
| | - Conor K McGarry
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Lisburn Road, Belfast, Northern Ireland; Cancer Centre Belfast City Hospital, Belfast Health & Social Care Trust, Lisburn Road, Belfast, Northern Ireland
| | - Aidan J Cole
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Lisburn Road, Belfast, Northern Ireland; Cancer Centre Belfast City Hospital, Belfast Health & Social Care Trust, Lisburn Road, Belfast, Northern Ireland
| | - Suneil Jain
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Lisburn Road, Belfast, Northern Ireland; Cancer Centre Belfast City Hospital, Belfast Health & Social Care Trust, Lisburn Road, Belfast, Northern Ireland
| | - Karl T Butterworth
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Lisburn Road, Belfast, Northern Ireland
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Kluge A, Ehrbar S, Grehn M, Fleckenstein J, Baus WW, Siebert FA, Schweikard A, Andratschke N, Mayinger MC, Boda-Heggemann J, Buergy D, Celik E, Krug D, Kovacs B, Saguner AM, Rudic B, Bergengruen P, Boldt LH, Stauber A, Zaman A, Bonnemeier H, Dunst J, Budach V, Blanck O, Mehrhof F. Treatment Planning for Cardiac Radioablation: Multicenter Multiplatform Benchmarking for the XXX Trial. Int J Radiat Oncol Biol Phys 2022; 114:360-372. [PMID: 35716847 DOI: 10.1016/j.ijrobp.2022.06.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 05/15/2022] [Accepted: 06/05/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Cardiac radioablation is a novel treatment option for patients with refractory ventricular tachycardia (VT) unsuitable for catheter ablation. The quality of treatment planning depends on dose specifications, platform capabilities, and experience of the treating staff. To harmonize the treatment planning, benchmarking of this process is necessary for multicenter clinical studies such as the XXX trial. METHODS AND MATERIALS Planning computed tomography data and consensus structures from three patients were sent to five academic centers for independent plan development using a variety of platforms and techniques with the XXX study protocol serving as guideline. Three-dimensional dose distributions and treatment plan details were collected and analyzed. In addition, an objective relative plan quality ranking system for VT treatments was established. RESULTS For each case, three coplanar volumetric modulated arc (VMAT) plans for C-arm linear accelerators (LINAC) and three non-coplanar treatment plans for robotic arm LINAC were generated. All plans were suitable for clinical applications with minor deviations from study guidelines in most centers. Eleven of 18 treatment plans showed maximal one minor deviation each for target and cardiac substructures. However, dose-volume histograms showed substantial differences: in one case, the PTV≥30Gy ranged from 0.0% to 79.9% and the RIVA V14Gy ranged from 4.0% to 45.4%. Overall, the VMAT plans had steeper dose gradients in the high dose region, while the plans for the robotic arm LINAC had smaller low dose regions. Thereby, VMAT plans required only about half as many monitor units, resulting in shorter delivery times, possibly an important factor in treatment outcome. CONCLUSIONS Cardiac radioablation is feasible with robotic arm and C-arm LINAC systems with comparable plan quality. Although cross-center training and best practice guidelines have been provided, further recommendations, especially for cardiac substructures, and ranking of dose guidelines will be helpful to optimize cardiac radioablation outcomes.
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Affiliation(s)
- Anne Kluge
- Klinik für Radioonkologie und Strahlentherapie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Stefanie Ehrbar
- Klinik für Radio-Onkologie, UniversitätsSpital Zürich, University of Zurich, Zürich, CH
| | - Melanie Grehn
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Jens Fleckenstein
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Wolfgang W Baus
- Department of Radiation Oncology and Cyberknife Center, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Frank-Andre Siebert
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Achim Schweikard
- University of Lübeck, Institute for Robotic and Cognitive Systems, Lübeck, Germany
| | - Nicolaus Andratschke
- Klinik für Radio-Onkologie, UniversitätsSpital Zürich, University of Zurich, Zürich, CH
| | - Michael C Mayinger
- Klinik für Radio-Onkologie, UniversitätsSpital Zürich, University of Zurich, Zürich, CH
| | - Judit Boda-Heggemann
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Daniel Buergy
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Eren Celik
- Department of Radiation Oncology and Cyberknife Center, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - David Krug
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Boldizsar Kovacs
- Universitäres Herzzentrum, Klinik für Kardiologie, UniversitätsSpital Zürich, University of Zurich, Zürich, CH
| | - Ardan M Saguner
- Universitäres Herzzentrum, Klinik für Kardiologie, UniversitätsSpital Zürich, University of Zurich, Zürich, CH
| | - Boris Rudic
- Medizinische Klinik, Universitätsmedizin Mannheim and German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Paula Bergengruen
- Klinik für Radioonkologie und Strahlentherapie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Leif-Hendrik Boldt
- Med. Klinik m.S. Kardiologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Annina Stauber
- Department of Radiation Oncology and Cyberknife Center, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Adrian Zaman
- Klinik für Innere Medizin III, Abteilung für Elektrophysiologie und Rhythmologie, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Hendrik Bonnemeier
- Klinik für Innere Medizin III, Abteilung für Elektrophysiologie und Rhythmologie, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Jürgen Dunst
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Volker Budach
- Klinik für Radioonkologie und Strahlentherapie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Oliver Blanck
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Felix Mehrhof
- Klinik für Radioonkologie und Strahlentherapie, Charité - Universitätsmedizin Berlin, Berlin, Germany.
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Lydiard S, Pontré B, Lowe BS, Keall P. Atrial fibrillation cardiac radioablation target visibility on magnetic resonance imaging. Phys Eng Sci Med 2022; 45:757-767. [PMID: 35687311 PMCID: PMC9448688 DOI: 10.1007/s13246-022-01141-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 05/16/2022] [Indexed: 11/27/2022]
Abstract
Magnetic resonance imaging (MRI) guided cardiac radioablation (CR) for atrial fibrillation (AF) is a promising treatment concept. However, the visibility of AF CR targets on MRI acquisitions requires further exploration and MRI sequence and parameter optimization has not yet been performed for this application. This pilot study explores the feasibility of MRI-guided tracking of AF CR targets by evaluating AF CR target visualization on human participants using a selection of 3D and 2D MRI sequences.MRI datasets were acquired in healthy and AF participants using a range of MRI sequences and parameters. MRI acquisition categories included 3D free-breathing acquisitions (3Dacq), 2D breath-hold ECG-gated acquisitions (2DECG-gated), stacks of 2D breath-hold ECG-gated acquisitions which were retrospectively interpolated to 3D datasets (3Dinterp), and 2D breath-hold ungated acquisitions (2Dreal-time). The ease of target delineation and the presence of artifacts were qualitatively analyzed. Image quality was quantitatively analyzed using signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR) and non-uniformity. Confident 3D target delineation was achievable on all 3Dinterp datasets but was not possible on any of the 3Dacq datasets. Fewer artifacts and significantly better SNR, CNR and non-uniformity metrics were observed with 3Dinterp compared to 3Dacq. 2Dreal-time datasets had slightly lower SNR and CNR than 2DECG-gated and 3Dinterp n datasets. AF CR target visualization on MRI was qualitatively and quantitatively evaluated. The study findings indicate that AF CR target visualization is achievable despite the imaging challenges associated with these targets, warranting further investigation into MRI-guided AF CR treatments.
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Affiliation(s)
- Suzanne Lydiard
- ACRF Image X Institute, University of Sydney, 1 Central Avenue, Eveleigh, NSW, Australia. .,Kathleen Kilgour Centre, 18 Twentieth Avenue, Tauranga South, Tauranga, New Zealand.
| | - Beau Pontré
- Department of Anatomy and Medical Imaging, University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand
| | - Boris S Lowe
- Green Lane Cardiovascular Service, Auckland City Hospital, 2 Park Road, Grafton, Auckland, New Zealand
| | - Paul Keall
- ACRF Image X Institute, University of Sydney, 1 Central Avenue, Eveleigh, NSW, Australia
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Perrin R, Maguire P, Garonna A, Weidlich G, Bulling S, Fargier-Voiron M, De Marco C, Rossi E, Ciocca M, Vitolo V, Mirandola A. Case Report: Treatment Planning Study to Demonstrate Feasibility of Transthoracic Ultrasound Guidance to Facilitate Ventricular Tachycardia Ablation With Protons. Front Cardiovasc Med 2022; 9:849247. [PMID: 35600462 PMCID: PMC9116532 DOI: 10.3389/fcvm.2022.849247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 03/28/2022] [Indexed: 12/17/2022] Open
Abstract
BackgroundCardiac arrhythmias, such as ventricular tachycardia, are disruptions in the normal cardiac function that originate from problems in the electrical conduction of signals inside the heart. Recently, a non-invasive treatment option based on external photon or proton beam irradiation has been used to ablate the arrhythmogenic structures. Especially in proton therapy, based on its steep dose gradient, it is crucial to monitor the motion of the heart in order to ensure that the radiation dose is delivered to the correct location. Transthoracic ultrasound imaging has the potential to provide guidance during this treatment delivery. However, it has to be noted that the presence of an ultrasound probe on the chest of the patient introduces constraints on usable beam angles for both protons and photon treatments. This case report investigates the possibility to generate a clinically acceptable proton treatment plan while the ultrasound probe is present on the chest of the patient.CaseA treatment plan study was performed based on a 4D cardiac-gated computed tomography scan of a 55 year-old male patient suffering from refractory ventricular tachycardia who underwent cardiac radioablation. A proton therapy treatment plan was generated for the actual treatment target in presence of an ultrasound probe on the chest of this patient. The clinical acceptability of the generated plan was confirmed by evaluating standard target dose-volume metrics, dose to organs-at-risk and target dose conformity and homogeneity.ConclusionThe generation of a clinically acceptable proton therapy treatment plan for cardiac radioablation of ventricular tachycardia could be performed in the presence of an ultrasound probe on the chest of the patient. These results establish a basis and justification for continued research and product development for ultrasound-guided cardiac radioablation.
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Affiliation(s)
| | | | - Adriano Garonna
- EBAMed SA, Geneva, Switzerland
- *Correspondence: Adriano Garonna
| | - Georg Weidlich
- Radiation Oncology, National Medical Physics and Dosimetry Company, Palo Alto, CA, United States
| | | | | | | | - Eleonora Rossi
- Centro Nazionale di Adroterapia Oncologica (CNAO), Pavia, Italy
| | - Mario Ciocca
- Centro Nazionale di Adroterapia Oncologica (CNAO), Pavia, Italy
| | - Viviana Vitolo
- Centro Nazionale di Adroterapia Oncologica (CNAO), Pavia, Italy
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Dvorak P, Knybel L, Dudas D, Benyskova P, Cvek J. Stereotactic Ablative Radiotherapy of Ventricular Tachycardia Using Tracking: Optimized Target Definition Workflow. Front Cardiovasc Med 2022; 9:870127. [PMID: 35586650 PMCID: PMC9108236 DOI: 10.3389/fcvm.2022.870127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 03/28/2022] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose Stereotactic arrhythmia radioablation (STAR) has been suggested as a promising therapeutic alternative in cases of failed catheter ablation for recurrent ventricular tachycardias in patients with structural heart disease. Cyberknife® robotic radiosurgery system utilizing target tracking technology is one of the available STAR treatment platforms. Tracking using implantable cardioverter-defibrillator lead tip as target surrogate marker is affected by the deformation of marker–target geometry. A simple method to account for the deformation in the target definition process is proposed. Methods Radiotherapy planning CT series include scans at expiration and inspiration breath hold, and three free-breathing scans. All secondary series are triple registered to the primary CT: 6D/spine + 3D translation/marker + 3D translation/target surrogate—a heterogeneous structure around the left main coronary artery. The 3D translation difference between the last two registrations reflects the deformation between the marker and the target (surrogate) for the respective respiratory phase. Maximum translation differences in each direction form an anisotropic geometry deformation margin (GDM) to expand the initial single-phase clinical target volume (CTV) to create an internal target volume (ITV) in the dynamic coordinates of the marker. Alternative GDM-based target volumes were created for seven recent STAR patients and compared to the original treated planning target volumes (PTVs) as well as to analogical volumes created using deformable image registration (DIR) by MIM® and Velocity® software. Intra- and inter-observer variabilities of the triple registration process were tested as components of the final ITV to PTV margin. Results A margin of 2 mm has been found to cover the image registration observer variability. GDM-based target volumes are larger and shifted toward the inspiration phase relative to the original clinical volumes based on a 3-mm isotropic margin without deformation consideration. GDM-based targets are similar (mean DICE similarity coefficient range 0.80–0.87) to their equivalents based on the DIR of the primary target volume delineated by dedicated software. Conclusion The proposed GDM method is a simple way to account for marker–target deformation-related uncertainty for tracking with Cyberknife® and better control of the risk of target underdose. The principle applies to general radiotherapy as well.
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Affiliation(s)
- Pavel Dvorak
- Department of Oncology, University Hospital Ostrava, Ostrava, Czechia
- Department of Radiation Protection, General University Hospital Prague, Praha, Czechia
| | - Lukas Knybel
- Department of Oncology, University Hospital Ostrava, Ostrava, Czechia
- *Correspondence: Lukas Knybel
| | - Denis Dudas
- Department of Oncology, University Hospital Motol, Praha, Czechia
| | - Pavla Benyskova
- Department of Oncology, University Hospital Ostrava, Ostrava, Czechia
| | - Jakub Cvek
- Department of Oncology, University Hospital Ostrava, Ostrava, Czechia
- Faculty of Medicine, University Hospital Ostrava, Ostrava, Czechia
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Casula M, Dusi V, Camps S, Gringet J, Benoit T, Garonna A, Rordorf R. Feasibility of an Automatic Ultrasonographic Image Acquisition System Associated With an Artificial Intelligence Algorithm for Real-Time Monitoring of Cardiac Motion During Cardiac Radio-Ablation. Front Cardiovasc Med 2022; 9:849234. [PMID: 35548427 PMCID: PMC9081646 DOI: 10.3389/fcvm.2022.849234] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 03/28/2022] [Indexed: 11/17/2022] Open
Abstract
Background The management of the cardio-respiratory motion of the target and the reduction of the uncertainties related to patient's positioning are two of the main challenges that stereotactic arrhythmia radio-ablation (STAR) has to overcome. A prototype of a system was developed that can automatically acquire and interpret echocardiographic images using an artificial intelligence (AI) algorithm to calculate cardiac displacement in real-time. Methods We conducted a single center study enrolling consecutive patients with a history of ventricular arrhythmias (VA) in order to evaluate the feasibility of this automatic acquisition system. Echocardiographic images were automatically acquired from the parasternal and apical views with a dedicated probe. The system was designed to hold the probe fixed to the chest in the supine position during both free-breathing and short expiratory breath-hold sequences, to simulate STAR treatment. The primary endpoint was the percentage of patients reaching a score ≥2 in a multi-parametric assessment evaluating the quality of automatically acquired images. Moreover, we investigated the potential impact of clinical and demographic characteristics on achieving the primary endpoint. Results We enrolled 24 patients (63 ± 14 years, 21% females). All of them had a history of VA and 21 (88%) had an ICD. Eight patients (33%) had coronary artery disease, 12 (50%) had non-ischemic cardiomyopathy, and 3 had idiopathic VA. Parasternal, as well as apical images were obtained from all patients except from one, in whom parasternal view could not be collected due to the patient's inability to maintain the supine position. The primary endpoint was achieved in 23 patients (96%) for the apical view, in 20 patients (87%) for the parasternal view, and in all patients in at least one of the two views. The images' quality was maximal (i.e., score = 4) in at least one of the two windows in 19 patients (79%). Atrial fibrillation arrhythmia was the only clinical characteristics associated with a poor score outcome in both imaging windows (apical p = 0.022, parasternal p = 0.014). Conclusions These results provide the proof-of-concept for the feasibility of an automatic ultrasonographic image acquisition system associated with an AI algorithm for real-time monitoring of cardiac motion in patients with a history of VA.
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Affiliation(s)
- Matteo Casula
- Arrhythmia and Electrophysiology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Section of Cardiology, Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Veronica Dusi
- Arrhythmia and Electrophysiology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Unit of Cardiology, AOU Città della Salute e della Scienza, Turin, Italy
| | | | | | | | | | - Roberto Rordorf
- Arrhythmia and Electrophysiology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- *Correspondence: Roberto Rordorf
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Akdag O, Borman PTS, Woodhead P, Uijtewaal P, Mandija S, Van Asselen B, Verhoeff JJC, Raaymakers BW, Fast MF. First experimental exploration of real-time cardiorespiratory motion management for future stereotactic arrhythmia radioablation treatments on the MR-linac. Phys Med Biol 2022; 67. [PMID: 35189610 DOI: 10.1088/1361-6560/ac5717] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 02/21/2022] [Indexed: 12/25/2022]
Abstract
Objective.Stereotactic arrhythmia radioablation (STAR) is a novel, non-invasive treatment for refractory ventricular tachycardia (VT). The VT isthmus is subject to both respiratory and cardiac motion. Rapid cardiac motion presents a unique challenge. In this study, we provide first experimental evidence for real-time cardiorespiratory motion-mitigated MRI-guided STAR on the 1.5 T Unity MR-linac (Elekta AB, Stockholm, Sweden) aimed at simultaneously compensating cardiac and respiratory motions.Approach.A real-time cardiorespiratory motion-mitigated radiotherapy workflow was developed on the Unity MR-linac in research mode. A 15-beam intensity-modulated radiation therapy treatment plan (1 × 25 Gy) was created in Monaco v.5.40.01 (Elekta AB) for the Quasar MRI4Dphantom (ModusQA, London, ON). A film dosimetry insert was moved by combining either artificial (cos4, 70 bpm, 10 mm peak-to-peak) or subject-derived (59 average bpm, 15.3 mm peak-to-peak) cardiac motion with respiratory (sin, 12 bpm, 20 mm peak-to-peak) motion. A balanced 2D cine MRI sequence (13 Hz, field-of-view = 400 × 207 mm2, resolution = 3 × 3 × 15 mm3) was developed to estimate cardiorespiratory motion. Cardiorespiratory motion was estimated by rigid registration and then deconvoluted into cardiac and respiratory components. For beam gating, the cardiac component was used, whereas the respiratory component was used for MLC-tracking. In-silico dose accumulation experiments were performed on three patient data sets to simulate the dosimetric effect of cardiac motion on VT targets.Main results.Experimentally, a duty cycle of 57% was achieved when simultaneously applying respiratory MLC-tracking and cardiac gating. Using film, excellent agreement was observed compared to a static reference delivery, resulting in a 1%/1 mm gamma pass rate of 99%. The end-to-end gating latency was 126 ms on the Unity MR-linac. Simulations showed that cardiac motion decreased the target's D98% dose between 0.1 and 1.3 Gy, with gating providing effective mitigation.Significance.Real-time MRI-guided cardiorespiratory motion management greatly reduces motion-induced dosimetric uncertainty and warrants further research and development for potential future use in STAR.
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Affiliation(s)
- O Akdag
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - P T S Borman
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - P Woodhead
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.,Elekta AB, Kungstensgatan 18, 113 57 Stockholm, Sweden
| | - P Uijtewaal
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - S Mandija
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.,Computational Imaging Group for MR Diagnostics and Therapy, Center for Image Sciences, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - B Van Asselen
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - J J C Verhoeff
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - B W Raaymakers
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - M F Fast
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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29
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Hayase J, Chin R, Cao M, Hu P, Shivkumar K, Bradfield JS. Non-invasive Stereotactic Body Radiation Therapy for Refractory Ventricular Arrhythmias: Venturing into the Unknown. J Innov Card Rhythm Manag 2022; 13:4894-4899. [PMID: 35251759 PMCID: PMC8887931 DOI: 10.19102/icrm.2022.130202] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 08/02/2021] [Indexed: 11/12/2022] Open
Abstract
Stereotactic body radiation therapy (SBRT) is a promising new method for non-invasive management of life-threatening ventricular arrhythmias. Numerous case reports and case series have provided encouraging short-term results suggesting good efficacy and safety, but randomized data and long-term outcomes are not yet available. The primary hypothesis as to the mechanism of action for SBRT relates to the development of cardiac fibrosis in arrhythmogenic myocardial substrate; however, limited animal model data offer conflicting insights into this theory. The use of SBRT for patients with refractory ventricular arrhythmias is rapidly increasing, but ongoing translational science work and randomized clinical trials will be critical to address many outstanding questions regarding this novel therapy.
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Affiliation(s)
- Justin Hayase
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Robert Chin
- Radiation Oncology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Minsong Cao
- Radiation Oncology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Peng Hu
- Department of Radiological Services, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Jason S Bradfield
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
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Di Monaco A, Gregucci F, Bonaparte I, Troisi F, Surgo A, Di Molfetta D, Vitulano N, Quadrini F, Carbonara R, Martinelli G, Guida P, Ciliberti MP, Fiorentino A, Grimaldi M. Paroxysmal Atrial Fibrillation in Elderly: Worldwide Preliminary Data of LINAC-Based Stereotactic Arrhythmia Radioablation Prospective Phase II Trial. Front Cardiovasc Med 2022; 9:832446. [PMID: 35310997 PMCID: PMC8924125 DOI: 10.3389/fcvm.2022.832446] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 02/08/2022] [Indexed: 12/31/2022] Open
Abstract
Treatment approach for elderly patients with atrial fibrillation (AF) is difficult. The present prospective phase-II trial evaluated LINAC-based stereotactic arrhythmia radioablation safety in this population. The reported data of the first 5 patients worldwide, showed no side effects, absence of AF episodes and without antiarrhythmic drugs.Trial Registration:ClinicalTrials.gov, identifier: NCT04575662.
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Affiliation(s)
- Antonio Di Monaco
- Department of Cardiology, General Regional Hospital F. Miulli, Bari, Italy
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Fabiana Gregucci
- Department of Radiation Oncology, General Regional Hospital F. Miulli, Bari, Italy
| | - Ilaria Bonaparte
- Department of Radiation Oncology, General Regional Hospital F. Miulli, Bari, Italy
| | - Federica Troisi
- Department of Cardiology, General Regional Hospital F. Miulli, Bari, Italy
| | - Alessia Surgo
- Department of Radiation Oncology, General Regional Hospital F. Miulli, Bari, Italy
| | | | - Nicola Vitulano
- Department of Cardiology, General Regional Hospital F. Miulli, Bari, Italy
| | - Federico Quadrini
- Department of Cardiology, General Regional Hospital F. Miulli, Bari, Italy
| | - Roberta Carbonara
- Department of Radiation Oncology, General Regional Hospital F. Miulli, Bari, Italy
| | - Gaetano Martinelli
- Department of Radiology, General Regional Hospital F. Miulli, Bari, Italy
| | - Pietro Guida
- Department of Cardiology, General Regional Hospital F. Miulli, Bari, Italy
| | | | - Alba Fiorentino
- Department of Radiation Oncology, General Regional Hospital F. Miulli, Bari, Italy
- *Correspondence: Alba Fiorentino
| | - Massimo Grimaldi
- Department of Cardiology, General Regional Hospital F. Miulli, Bari, Italy
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31
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Bellec J, Rigal L, Hervouin A, Martins R, Lederlin M, Jaksic N, Castelli J, Benali K, de Crevoisier R, Simon A. Cardiac radioablation for ventricular tachycardia: Which approach for incorporating cardiorespiratory motions into the planning target volume? Phys Med 2022; 95:16-24. [DOI: 10.1016/j.ejmp.2022.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 01/10/2022] [Accepted: 01/11/2022] [Indexed: 10/19/2022] Open
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Q. M. Reis C, Little B, Lee MacDonald R, Syme A, Thomas CG, Robar JL. SBRT of ventricular tachycardia using 4pi optimized trajectories. J Appl Clin Med Phys 2021; 22:72-86. [PMID: 34679247 PMCID: PMC8664144 DOI: 10.1002/acm2.13454] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 09/05/2021] [Accepted: 10/03/2021] [Indexed: 12/19/2022] Open
Abstract
PURPOSE To investigate the possible advantages of using 4pi-optimized arc trajectories in stereotactic body radiation therapy of ventricular tachycardia (VT-SBRT) to minimize exposure of healthy tissues. METHODS AND MATERIALS Thorax computed tomography (CT) data for 15 patients were used for contouring organs at risk (OARs) and defining realistic planning target volumes (PTVs). A conventional trajectory plan, defined as two full coplanar arcs was compared to an optimized-trajectory plan provided by a 4pi algorithm that penalizes geometric overlap of PTV and OARs in the beam's-eye-view. A single fraction of 25 Gy was prescribed to the PTV in both plans and a comparison of dose sparing to OARs was performed based on comparisons of maximum, mean, and median dose. RESULTS A significant average reduction in maximum dose was observed for esophagus (18%), spinal cord (26%), and trachea (22%) when using 4pi-optimized trajectories. Mean doses were also found to decrease for esophagus (19%), spinal cord (33%), skin (18%), liver (59%), lungs (19%), trachea (43%), aorta (11%), inferior vena cava (25%), superior vena cava (33%), and pulmonary trunk (26%). A median dose reduction was observed for esophagus (40%), spinal cord (48%), skin (36%), liver (72%), lungs (41%), stomach (45%), trachea (53%), aorta (45%), superior vena cava (38%), pulmonary veins (32%), and pulmonary trunk (39%). No significant difference was observed for maximum dose (p = 0.650) and homogeneity index (p = 0.156) for the PTV. Average values of conformity number were 0.86 ± 0.05 and 0.77 ± 0.09 for the conventional and 4pi optimized plans respectively. CONCLUSIONS 4pi optimized trajectories provided significant reduction to mean and median doses to cardiac structures close to the target but did not decrease maximum dose. Significant improvement in maximum, mean and median doses for noncardiac OARs makes 4pi optimized trajectories a suitable delivery technique for treating VT.
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Affiliation(s)
- Cristiano Q. M. Reis
- Department of Radiation OncologyDalhousie UniversityHalifaxNova ScotiaCanada
- Department of Medical PhysicsScotia Health Authority, NovaHalifaxNova ScotiaCanada
- Department of Physics and Atmospheric ScienceDalhousie UniversityHalifaxNova ScotiaCanada
- Department of Radiation Oncology, London Regional Cancer ProgramLondon Health Sciences Centre790 Commissioners Road EastLondonONN6A 4L6Canada
| | - Brian Little
- Department of Radiation OncologyDalhousie UniversityHalifaxNova ScotiaCanada
- Department of Medical PhysicsScotia Health Authority, NovaHalifaxNova ScotiaCanada
- Department of Physics and Atmospheric ScienceDalhousie UniversityHalifaxNova ScotiaCanada
- Adaptiiv Medical Technologies Inc405‐1344 Summer Street Halifax, NS B3H 0A8Canada
| | - Robert Lee MacDonald
- Department of Radiation OncologyDalhousie UniversityHalifaxNova ScotiaCanada
- Department of Medical PhysicsScotia Health Authority, NovaHalifaxNova ScotiaCanada
- Department of Physics and Atmospheric ScienceDalhousie UniversityHalifaxNova ScotiaCanada
| | - Alasdair Syme
- Department of Radiation OncologyDalhousie UniversityHalifaxNova ScotiaCanada
- Department of Medical PhysicsScotia Health Authority, NovaHalifaxNova ScotiaCanada
- Department of Physics and Atmospheric ScienceDalhousie UniversityHalifaxNova ScotiaCanada
- Beatrice Hunter Cancer Research InstituteHalifaxNova ScotiaCanada
| | - Christopher G. Thomas
- Department of Radiation OncologyDalhousie UniversityHalifaxNova ScotiaCanada
- Department of Medical PhysicsScotia Health Authority, NovaHalifaxNova ScotiaCanada
- Department of Physics and Atmospheric ScienceDalhousie UniversityHalifaxNova ScotiaCanada
- Beatrice Hunter Cancer Research InstituteHalifaxNova ScotiaCanada
- Department of RadiologyDalhousie UniversityHalifaxNova ScotiaCanada
| | - James L. Robar
- Department of Radiation OncologyDalhousie UniversityHalifaxNova ScotiaCanada
- Department of Medical PhysicsScotia Health Authority, NovaHalifaxNova ScotiaCanada
- Department of Physics and Atmospheric ScienceDalhousie UniversityHalifaxNova ScotiaCanada
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Lydiard S, Pontré B, Hindley N, Lowe BS, Sasso G, Keall P. MRI-guided cardiac-induced target motion tracking for atrial fibrillation cardiac radioablation. Radiother Oncol 2021; 164:138-145. [PMID: 34597739 DOI: 10.1016/j.radonc.2021.09.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 09/13/2021] [Accepted: 09/22/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND PURPOSE Atrial fibrillation (AF) cardiac radioablation (CR) challenges radiotherapy tracking: multiple small targets close to organs-at-risk undergo rapid differential cardiac contraction and respiratory motion. MR-guidance offers a real-time target tracking solution. This work develops and investigates MRI-guided tracking of AF CR targets with cardiac-induced motion. MATERIALS AND METHODS A direct tracking method (Trackingdirect) and two indirect tracking methods leveraging population-based surrogacy relationships with the left atria (Trackingindirect_LA) or other target (Trackingindirect_target) were developed. Tracking performance was evaluated using transverse ECG-gated breathhold MRI images from 15 healthy and 10 AF participants. Geometric and volumetric tracking errors were calculated, defined as the difference between the ground-truth and tracked target centroids and volumes respectively. Transverse, breath-hold, noncardiac-gated cine images were acquired at 4 Hz in 5 healthy and 5 AF participants to qualitatively characterize tracking performance on images more comparable to MRILinac acquisitions. RESULTS The average 3D geometric tracking errors for Trackingdirect, Trackingindirect_LA and Trackingindirect_target respectively were 1.7 ± 1.2 mm, 1.6 ± 1.1 mm and 1.9 ± 1.3 mm in healthy participants and 1.7 ± 1.3 mm, 1.5 ± 1.0 mm and 1.7 ± 1.2 mm in AF participants. For Trackingdirect, 88% of analyzed images had 3D geometric tracking errors <3 mm and the average volume tracking error was 1.7 ± 1.3 cc. For Trackingdirect on non-cardiac-gated cine images, tracked targets overlapped organsat-risk or completely missed the target area on 2.2% and 0.08% of the images respectively. CONCLUSION The feasibility of non-invasive MRI-guided tracking of cardiac-induced AF CR target motion was demonstrated for the first time, showing potential for improving AF CR treatment efficacy.
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Affiliation(s)
- Suzanne Lydiard
- ACRF Image X Institute, University of Sydney, Eveleigh, Australia.
| | - Beau Pontré
- Department of Anatomy and Medical Imaging, University of Auckland, New Zealand
| | - Nicholas Hindley
- ACRF Image X Institute, University of Sydney, Eveleigh, Australia
| | - Boris S Lowe
- Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand
| | - Giuseppe Sasso
- Department of Anatomy and Medical Imaging, University of Auckland, New Zealand; Radiation Oncology Department, Auckland City Hospital, New Zealand; Department of Oncology, University of Auckland, New Zealand
| | - Paul Keall
- ACRF Image X Institute, University of Sydney, Eveleigh, Australia
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Hindley N, Lydiard S, Shieh CC, Keall P. Proof-of-concept for x-ray based real-time image guidance during cardiac radioablation. Phys Med Biol 2021; 66. [PMID: 34315136 DOI: 10.1088/1361-6560/ac1834] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/27/2021] [Indexed: 11/11/2022]
Abstract
Cardiac radioablation offers non-invasive treatments for refractory arrhythmias. However, treatment delivery for this technique remains challenging. In this paper, we introduce the first method for real-time image guidance during cardiac radioablation for refractory atrial fibrillation on a standard linear accelerator. Our proposed method utilizes direct diaphragm tracking on intrafraction images to estimate the respiratory component of cardiac substructure motion. We compare this method to treatment scenarios without real-time image guidance using the 4D-XCAT digital phantom. Pre-treatment and intrafraction imaging was simulated for 8 phantoms with unique anatomies programmed using cardiorespiratory motion from healthy volunteers. As every voxel in the 4D-XCAT phantom is labelled precisely according to the corresponding anatomical structure, this provided ground-truth for quantitative evaluation. Tracking performance was compared to the ground-truth for simulations with and without real-time image guidance using the left atrium as an exemplar target. Differences in target volume size, mean volumetric coverage, minimum volumetric coverage and geometric error were recorded for each simulation. We observed that differences in target volume size were statistically significant (p < 0.001) across treatment scenarios and that real-time image guidance enabled reductions in target volume size ranging from 11% to 24%. Differences in mean and minimum volumetric coverage were statistically insignificant (bothp = 0.35) while differences in geometric error were statistically significant (p = 0.039). The results of this study provide proof-of-concept for x-ray based real-time image guidance during cardiac radioablation.
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Affiliation(s)
| | - Suzanne Lydiard
- ACRF Image X Institute, University of Sydney, Sydney, Australia.,Ingham Institute for Applied Medical Research, Liverpool, Australia
| | - Chun-Chien Shieh
- ACRF Image X Institute, University of Sydney, Sydney, Australia.,Sydney Neuroimaging Analysis Centre, University of Sydney, Sydney, Australia
| | - Paul Keall
- ACRF Image X Institute, University of Sydney, Sydney, Australia
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Krug D, Blanck O, Andratschke N, Guckenberger M, Jumeau R, Mehrhof F, Boda-Heggemann J, Seidensaal K, Dunst J, Pruvot E, Scholz E, Saguner AM, Rudic B, Boldt LH, Bonnemeier H. Recommendations regarding cardiac stereotactic body radiotherapy for treatment refractory ventricular tachycardia. Heart Rhythm 2021; 18:2137-2145. [PMID: 34380072 DOI: 10.1016/j.hrthm.2021.08.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 08/02/2021] [Accepted: 08/03/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Ventricular tachycardia (VT) is a potentially lethal complication of structural heart disease. Despite optimal management, a subgroup of patients continue to suffer from recurrent VT. Recently, cardiac stereotactic body radiotherapy (CSBRT) has been introduced as a treatment option in patients with VT refractory to antiarrhythmic drugs and catheter ablation. OBJECTIVE The purpose of this study was to establish an expert consensus regarding the conduct and use of CSBRT for refractory VT. METHODS We conducted a modified Delphi process. Thirteen experts from institutions from Germany and Switzerland participated in the modified Delphi process. Statements regarding the following topics were generated: treatment setting, institutional expertise and technical requirements, patient selection, target volume definition, and monitoring during and after CSBRT. Agreement was rated on a 5-point Likert scale. Cutoffs for agreement were defined in analogy to the RAND methodology. RESULTS There was strong agreement regarding the experimental status of the procedure and the preference for treatment in clinical trials. CSBRT should be conducted at specialized centers with a strong expertise in the management of patients with ventricular arrhythmias and in stereotactic body radiotherapy for moving targets. CSBRT should be restricted to patients with refractory VT with optimal antiarrhythmic medication who underwent prior catheter ablation or have contraindications. Target volume delineation for CSBRT is complex. Therefore, interdisciplinary processes that should include cardiology/electrophysiology and radiation oncology as well as medical physics, radiology, and nuclear medicine are needed. Optimal follow-up is required. CONCLUSION Prospective trials and pooled registries are needed to gain further insight into this promising treatment option for patients with refractory VT.
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Affiliation(s)
- David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany.
| | - Oliver Blanck
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | | | - Raphael Jumeau
- Department of Radiation Oncology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; Radiation Oncology Institute, Hirslanden Clinique Bois-Cerf, Lausanne, Switzerland
| | - Felix Mehrhof
- Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Judit Boda-Heggemann
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Medical Faculty Mannheim, Mannheim, Germany
| | - Katharina Seidensaal
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
| | - Jürgen Dunst
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Etienne Pruvot
- Heart and Vessel Department, Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Eberhard Scholz
- Department of Cardiology, Heidelberg Center for Heart Rhythm Disorders (HCR), University of Heidelberg, Heidelberg, Germany
| | - Ardan M Saguner
- Department of Cardiology, University Heart Center Zurich, Zurich, Switzerland
| | - Boris Rudic
- Department of Internal Medicine I, Section for Electrophysiology und Rhythmology, University Medical Center Mannheim, University of Heidelberg, Medical Faculty Mannheim, Mannheim, Germany
| | - Leif-Hendrik Boldt
- Department of Internal Medicine and Cardiology, Charité University Medicine Berlin-Campus Virchow Klinikum, Berlin, Germany
| | - Hendrik Bonnemeier
- Department of Internal Medicine III, Section for Electrophysiology und Rhythmology, University Hospital Schleswig-Holstein, Kiel, Germany
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Krug D, Blanck O, Dunst J, Bonnemeier H. Stereotactic ablative radiotherapy for cardiac arrhythmia - A rising STAR? Trends Cardiovasc Med 2021; 32:297-298. [PMID: 34062260 DOI: 10.1016/j.tcm.2021.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 05/22/2021] [Indexed: 11/24/2022]
Affiliation(s)
- D Krug
- Department of Radiation Oncology, University Hospital Schleswig- Holstein, Campus Kiel, Arnold-Heller-Str. 3, Haus L, Kiel 24105, Germany.
| | - O Blanck
- Department of Radiation Oncology, University Hospital Schleswig- Holstein, Campus Kiel, Arnold-Heller-Str. 3, Haus L, Kiel 24105, Germany
| | - J Dunst
- Department of Radiation Oncology, University Hospital Schleswig- Holstein, Campus Kiel, Arnold-Heller-Str. 3, Haus L, Kiel 24105, Germany
| | - H Bonnemeier
- Department of Internal Medicine III, Section for Electrophysiology und Rhythmology, University Hospital Schleswig- Holstein, Campus Kiel, Kiel, Germany
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Miszczyk M, Jadczyk T, Gołba K, Wojakowski W, Wita K, Bednarek J, Blamek S. Clinical Evidence behind Stereotactic Radiotherapy for the Treatment of Ventricular Tachycardia (STAR)-A Comprehensive Review. J Clin Med 2021; 10:jcm10061238. [PMID: 33802802 PMCID: PMC8002399 DOI: 10.3390/jcm10061238] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 03/14/2021] [Accepted: 03/15/2021] [Indexed: 12/31/2022] Open
Abstract
The electrophysiology-guided noninvasive cardiac radioablation, also known as STAR (stereotactic arrhythmia radioablation) is an emerging treatment method for persistent ventricular tachycardia. Since its first application in 2012 in Stanford Cancer Institute, and a year later in University Hospital Ostrava, Czech Republic, the authors from all around the world have published case reports and case series, and several prospective trials were established. In this article, we would like to discuss the available clinical evidence, analyze the potentially clinically relevant differences in methodology, and address some of the unique challenges that come with this treatment method.
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Affiliation(s)
- Marcin Miszczyk
- IIIrd Department of Radiotherapy and Chemotherapy, Maria Sklodowska-Curie National Research Institute of Oncology, 44-102 Gliwice, Poland
- Correspondence: ; Tel.: +48-663-040-809
| | - Tomasz Jadczyk
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, 40-055 Katowice, Poland; (T.J.); (W.W.)
- International Clinical Research Center, Interventional Cardiac Electrophysiology Group, St. Anne’s University Hospital Brno, 664/53 Brno, Czech Republic
| | - Krzysztof Gołba
- Upper-Silesian Heart Center, Department of Electrocardiology, 40-055 Katowice, Poland;
- Department of Electrocardiology and Heart Failure, Medical University of Silesia, 40-055 Katowice, Poland
| | - Wojciech Wojakowski
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, 40-055 Katowice, Poland; (T.J.); (W.W.)
| | - Krystian Wita
- First Department of Cardiology, Medical University of Silesia, 40-055 Katowice, Poland;
| | - Jacek Bednarek
- Department of Electrocardiology, John Paul II Hospital, 31-202 Cracow, Poland;
| | - Sławomir Blamek
- Department of Radiotherapy, Maria Sklodowska-Curie National Research Institute of Oncology, 44-102 Gliwice, Poland;
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