1
|
Huijskens S, Granton P, Fremeijer K, van Wanrooij C, Offereins-van Harten K, Schouwenaars-van den Beemd S, Hoogeman MS, Sattler MGA, Penninkhof J. Clinical practicality and patient performance for surface-guided automated VMAT gating for DIBH breast cancer radiotherapy. Radiother Oncol 2024; 195:110229. [PMID: 38492672 DOI: 10.1016/j.radonc.2024.110229] [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: 12/22/2023] [Revised: 03/11/2024] [Accepted: 03/12/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND AND PURPOSE To evaluate the performance of automated surface-guided gating for left-sided breast cancer with DIBH and VMAT. MATERIALS AND METHODS Patients treated in the first year after introduction of DIBH with VMAT were retrospectively considered for analysis. With automated surface-guided gating the beam automatically switches on/off, if the surface region of interest moved in/out the gating tolerance (±3 mm, ±3°). Patients were coached to hold their breath as long as comfortably possible. Depending on the patient's preference, patients received audio instructions during treatment delivery. Real-time positional variations of the breast/chest wall surface with respect to the reference surface were collected, for all three orthogonal directions. The durations and number of DIBHs needed to complete dose delivery, and DIBH position variations were determined. To evaluate an optimal gating window threshold, smaller tolerances of ±2.5 mm, ±2.0 mm, and ±1.5 mm were simulated. RESULTS 525 fractions from 33 patients showed that median DIBH duration was 51 s (range: 30-121 s), and median 4 DIBHs per fraction were needed to complete VMAT dose delivery. Median intra-DIBH stability and intrafractional DIBH reproducibility approximated 1.0 mm in each direction. No large differences were found between patients who preferred to perform the DIBH procedure with (n = 21) and without audio-coaching (n = 12). Simulations demonstrated that gating window tolerances could be reduced from ±3.0 mm to ±2.0 mm, without affecting beam-on status. CONCLUSION Independent of the use of audio-coaching, this study demonstrates that automated surface-guided gating with DIBH and VMAT proved highly efficient. Patients' DIBH performance far exceeded our expectations compared to earlier experiences and literature. Furthermore, gating window tolerances could be reduced.
Collapse
Affiliation(s)
- Sophie Huijskens
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Rotterdam, the Netherlands.
| | - Patrick Granton
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Rotterdam, the Netherlands
| | - Kimm Fremeijer
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Rotterdam, the Netherlands
| | - Cynthia van Wanrooij
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Rotterdam, the Netherlands
| | - Kirsten Offereins-van Harten
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Rotterdam, the Netherlands
| | | | - Mischa S Hoogeman
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Rotterdam, the Netherlands
| | - Margriet G A Sattler
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Rotterdam, the Netherlands
| | - Joan Penninkhof
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Rotterdam, the Netherlands
| |
Collapse
|
2
|
Zhao F, Zhou ZY, Wang YQ, Jiang YT, Wang YXJ, Yu H, Yu HG, Bu LY, Lu ZJ, Yao GR, Yan SX. A Convenient and Effective Preoxygenation Technique for Prolonging Deep Inspiration Breath-Hold Duration With a Venturi Mask With a 50% Oxygen Concentration. Pract Radiat Oncol 2024; 14:e87-e96. [PMID: 37871850 DOI: 10.1016/j.prro.2023.10.003] [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: 08/05/2023] [Revised: 09/29/2023] [Accepted: 10/06/2023] [Indexed: 10/25/2023]
Abstract
PURPOSE Voluntary deep inspiration breath-hold (DIBH) is commonly used in radiation therapy (RT), but the short duration of a single breath-hold, estimated to be around 20 to 40 seconds, is a limitation. This prospective study aimed to assess the feasibility and safety of using a simple preoxygenation technique with a Venturi mask to prolong voluntary DIBH. METHODS AND MATERIALS The study included 33 healthy volunteers and 21 RT patients. Preoxygenation was performed using a Venturi mask with a 50% oxygen concentration. Paired t tests compared the duration of a single DIBH in room air and after 5, 15, and 30 minutes of preoxygenation in healthy volunteers. Sustainability of breath-hold and tolerability of heart rate and blood pressure were assessed for multiple DIBH durations in both volunteers and patients. RESULTS In healthy volunteers, a 15-minute preoxygenation significantly prolonged the duration of a single DIBH by 24.95 seconds compared with 5-minute preoxygenation (89 ± 27.76 vs 113.95 ± 30.63 seconds; P < .001); although there was a statistically significant increase in DIBH duration after 30-minute preoxygenation, it was only extended by 4.95 seconds compared with 15-minute preoxygenation (113.95 ± 30.63 vs 118.9 ± 29.77 seconds; P < .01). After 15-minute preoxygenation, a single DIBH lasted over 100 seconds in healthy volunteers and over 80 seconds in RT patients, with no significant differences among 6 consecutive cycles of DIBH. Furthermore, there were no significant differences in heart rate or blood pressure after DIBHs, including DIBH in room air and 6 consecutive DIBHs after 15-minute preoxygenation (all P > .05). CONCLUSIONS Preoxygenation with a 50% oxygen concentration for 15 minutes effectively prolongs the duration of 6 cycles of DIBH both in healthy volunteers and RT patients. The utilization of a Venturi mask to deliver 50% oxygen concentration provides a solution characterized by its convenience, good tolerability, and effectiveness.
Collapse
Affiliation(s)
- Feng Zhao
- Department of Radiation Oncology, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China; Cancer Center, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China.
| | - Zi-Yang Zhou
- Department of Radiation Oncology, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China; Graduate School, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Yi-Qi Wang
- Department of Radiation Oncology, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China; Graduate School, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Yan-Ting Jiang
- Department of Radiation Oncology, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China; Graduate School, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Yi-Xiang J Wang
- Department of Imaging and Interventional Radiology, the Chinese University of Hong Kong, Hong Kong, People's Republic of China
| | - Hao Yu
- Department of Radiation Oncology, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China; Graduate School, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Hao-Gang Yu
- Department of Radiation Oncology, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China; Cancer Center, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Lu-Yi Bu
- Department of Radiation Oncology, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China; Cancer Center, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Zhong-Jie Lu
- Department of Radiation Oncology, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China; Cancer Center, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Guo-Rong Yao
- Department of Radiation Oncology, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China; Cancer Center, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China.
| | - Sen-Xiang Yan
- Department of Radiation Oncology, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China; Cancer Center, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China.
| |
Collapse
|
3
|
Abdelaziz MEMK, Zhao J, Gil Rosa B, Lee HT, Simon D, Vyas K, Li B, Koguna H, Li Y, Demircali AA, Uvet H, Gencoglan G, Akcay A, Elriedy M, Kinross J, Dasgupta R, Takats Z, Yeatman E, Yang GZ, Temelkuran B. Fiberbots: Robotic fibers for high-precision minimally invasive surgery. SCIENCE ADVANCES 2024; 10:eadj1984. [PMID: 38241380 PMCID: PMC10798568 DOI: 10.1126/sciadv.adj1984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 12/20/2023] [Indexed: 01/21/2024]
Abstract
Precise manipulation of flexible surgical tools is crucial in minimally invasive surgical procedures, necessitating a miniature and flexible robotic probe that can precisely direct the surgical instruments. In this work, we developed a polymer-based robotic fiber with a thermal actuation mechanism by local heating along the sides of a single fiber. The fiber robot was fabricated by highly scalable fiber drawing technology using common low-cost materials. This low-profile (below 2 millimeters in diameter) robotic fiber exhibits remarkable motion precision (below 50 micrometers) and repeatability. We developed control algorithms coupling the robot with endoscopic instruments, demonstrating high-resolution in situ molecular and morphological tissue mapping. We assess its practicality and safety during in vivo laparoscopic surgery on a porcine model. High-precision motion of the fiber robot delivered endoscopically facilitates the effective use of cellular-level intraoperative tissue identification and ablation technologies, potentially enabling precise removal of cancer in challenging surgical sites.
Collapse
Affiliation(s)
- Mohamed E. M. K. Abdelaziz
- The Hamlyn Centre for Robotic Surgery, Imperial College London, London SW7 2AZ, UK
- Department of Electrical and Electronic Engineering, Faculty of Engineering, Imperial College London, London SW7 2AZ, UK
| | - Jinshi Zhao
- The Hamlyn Centre for Robotic Surgery, Imperial College London, London SW7 2AZ, UK
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London SW7 2AZ, UK
| | - Bruno Gil Rosa
- The Hamlyn Centre for Robotic Surgery, Imperial College London, London SW7 2AZ, UK
- Department of Electrical and Electronic Engineering, Faculty of Engineering, Imperial College London, London SW7 2AZ, UK
| | - Hyun-Taek Lee
- Department of Mechanical Engineering, Inha University, Incheon 22212, South Korea
| | - Daniel Simon
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London SW7 2AZ, UK
- The Rosalind Franklin Institute, Didcot OX11 0QS, UK
| | - Khushi Vyas
- The Hamlyn Centre for Robotic Surgery, Imperial College London, London SW7 2AZ, UK
- Department of Electrical and Electronic Engineering, Faculty of Engineering, Imperial College London, London SW7 2AZ, UK
| | - Bing Li
- The UK DRI Care Research and Technology Centre, Department of Brain Science, Imperial College London, London W12 0MN, UK
- Institute for Materials Discovery, University College London, London WC1H 0AJ, UK
| | - Hanifa Koguna
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London SW7 2AZ, UK
| | - Yue Li
- The Hamlyn Centre for Robotic Surgery, Imperial College London, London SW7 2AZ, UK
| | - Ali Anil Demircali
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London SW7 2AZ, UK
| | - Huseyin Uvet
- Department of Mechatronics Engineering, Faculty of Engineering, Yildiz Technical University, Istanbul 34349, Turkey
| | - Gulsum Gencoglan
- Department of Dermatology and Venereology, Liv Hospital Vadistanbul, Istanbul 34396, Turkey
- Department of Skin and Venereal Diseases, Faculty of Medicine, Istinye University, Istanbul 34010, Turkey
| | - Arzu Akcay
- Department of Pathology, Faculty of Medicine, Yeni Yüzyıl University, Istanbul 34010, TR
- Pathology Laboratory, Atakent Hospital, Acibadem Mehmet Ali Aydinlar University, Istanbul 34303, TR
| | - Mohamed Elriedy
- Anesthesiology, University Hospitals of Derby and Burton, Derby, DE22 3NE, UK
| | - James Kinross
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London SW7 2AZ, UK
| | - Ranan Dasgupta
- Department of Urology, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London W6 8RF, UK
| | - Zoltan Takats
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London SW7 2AZ, UK
- The Rosalind Franklin Institute, Didcot OX11 0QS, UK
| | - Eric Yeatman
- Department of Electrical and Electronic Engineering, Faculty of Engineering, Imperial College London, London SW7 2AZ, UK
| | - Guang-Zhong Yang
- Institute of Medical Robots, Shanghai Jiao Tong University, Shanghai 200240, China
| | - Burak Temelkuran
- The Hamlyn Centre for Robotic Surgery, Imperial College London, London SW7 2AZ, UK
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London SW7 2AZ, UK
- The Rosalind Franklin Institute, Didcot OX11 0QS, UK
| |
Collapse
|
4
|
Towell V, Gysen KV, Cross S, KK Low G. Efficacy of preoxygenation administration in volunteers, in extending the end-expiration breath-hold duration for application to abdominal radiotherapy. Tech Innov Patient Support Radiat Oncol 2023; 26:100208. [PMID: 37207259 PMCID: PMC10189463 DOI: 10.1016/j.tipsro.2023.100208] [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: 01/24/2023] [Revised: 04/02/2023] [Accepted: 04/18/2023] [Indexed: 05/21/2023] Open
Abstract
Background and purpose End expiration breath hold (EEBH) is the preferred motion management method for abdominal Stereotactic Ablative Body Radiotherapy (SABR) treatments. However, multiple short EEBHs are required to complete a single treatment session. The study aimed to determine the efficacy of preoxygenation with hyperventilation in extending an EEBH duration. Materials and methods We randomised 10 healthy participants into two arms, each included breathing room air and oxygen at a rate of 10 L per minute (l/min) without hyperventilation for four minutes, and normally for four minutes and with hyperventilation for one minute at a rate of 20 breaths/minute for hyperventilation. The type of gas was blinded from the participants for each test. EEBH durations were then recorded, as well as systolic blood pressure, SpO2 and heart rate. A discomfort rating was also recorded after each breath hold. Results A significant increase in duration of almost 50% was observed between normal breathing of room air and breathing oxygen normally followed by hyperventilation. Vital signs remained consistent between the 4 tests. The tests were well tolerated with 75% of participants recording none or minimal discomfort. Conclusion Preoxygenation with hyperventilation could be used to increase the EEBH duration for abdominal SABR patients which would assist in the accuracy of these treatments and possibly resulting in a reduction of overall treatment times.
Collapse
Affiliation(s)
- Vincent Towell
- Department of Radiation Oncology, Nepean Hospital Cancer Care Centre, Sydney, Australia
- Corresponding author.
| | - Kirsten Van Gysen
- Department of Radiation Oncology, Nepean Hospital Cancer Care Centre, Sydney, Australia
- Nepean Clinical School, University of Sydney, Sydney, Australia
| | - Shamira Cross
- Department of Radiation Oncology, Nepean Hospital Cancer Care Centre, Sydney, Australia
- Nepean Clinical School, University of Sydney, Sydney, Australia
| | - Gary KK Low
- Research Operations, Nepean Hospital, Sydney, Australia
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| |
Collapse
|
5
|
Parkes MJ, Green S, Cashmore J, Ghafoor Q, Clutton-Brock T. Shortening the preparation time of the single prolonged breath-hold for radiotherapy sessions. Br J Radiol 2021; 95:20210408. [PMID: 34930022 PMCID: PMC8822572 DOI: 10.1259/bjr.20210408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Objective: Single prolonged breath-holds of >5 min can be obtained in cancer patients. Currently, however, the preparation time in each radiotherapy session is a practical limitation for clinical adoption of this new technique. Here, we show by how much our original preparation time can be shortened without unduly compromising breath-hold duration. Methods: 44 healthy subjects performed single prolonged breath-holds from 60% O2 and mechanically induced hypocapnia. We tested the effect on breath-hold duration of shortening preparation time (the durations of acclimatization, hyperventilation and hypocapnia) by changing these durations and or ventilator settings. Results: Mean original breath-hold duration was 6.5 ± 0.2 (standard error) min. The total original preparation time (from connecting the facemask to the start of the breath-hold) was 26 ± 1 min. After shortening the hypocapnia duration from 16 to 5 min, mean breath-hold duration was still 6.1 ± 0.2 min (ns vs the original). After abolishing the acclimatization and shortening the hypocapnia to 1 min (a total preparation time now of 9 ± 1 min), a mean breath-hold duration of >5 min was still possible (now significantly shortened to 5.2 ± 0.6 min, p < 0.001). After shorter and more vigorous hyperventilation (lasting 2.7 ± 0.3 min) and shorter hypocapnia (lasting 43 ± 4 s), a mean breath-hold duration of >5 min (5.3 ± 0.2 min, p < 0.05) was still possible. Here, the final total preparation time was 3.5 ± 0.3 min. Conclusions: These improvements may facilitate adoption of the single prolonged breath-hold for a range of thoracic and abdominal radiotherapies especially involving hypofractionation. Advances in knowledge: Multiple short breath-holds improve radiotherapy for thoracic and abdominal cancers. Further improvement may occur by adopting the single prolonged breath-hold of >5 min. One limitation to clinical adoption is its long preparation time. We show here how to reduce the mean preparation time from 26 to 3.5 min without compromising breath-hold duration
Collapse
Affiliation(s)
- Michael John Parkes
- School of Sport, Exercise & Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom.,National Institute for Health Research (NIHR)/Wellcome Trust Birmingham Clinical Research Facility, Birmingham, United Kingdom.,Hall Edwards Radiotherapy Group, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.,Marie Sklodowska-Curie Fellow, Department of Radiation Oncology, University Medical Centre, Amsterdam, Netherlands
| | - Stuart Green
- Hall Edwards Radiotherapy Group, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Jason Cashmore
- Hall Edwards Radiotherapy Group, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Qamar Ghafoor
- Hall Edwards Radiotherapy Group, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Thomas Clutton-Brock
- National Institute for Health Research (NIHR)/Wellcome Trust Birmingham Clinical Research Facility, Birmingham, United Kingdom.,Department of Anaesthesia and Intensive Care Medicine, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| |
Collapse
|
6
|
Emert F, Missimer J, Eichenberger PA, Walser M, Gmür C, Lomax AJ, Weber DC, Spengler CM. Enhanced Deep-Inspiration Breath Hold Superior to High-Frequency Percussive Ventilation for Respiratory Motion Mitigation: A Physiology-Driven, MRI-Guided Assessment Toward Optimized Lung Cancer Treatment With Proton Therapy. Front Oncol 2021; 11:621350. [PMID: 33996545 PMCID: PMC8116693 DOI: 10.3389/fonc.2021.621350] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 02/18/2021] [Indexed: 12/25/2022] Open
Abstract
Background: To safely treat lung tumors using particle radiation therapy (PRT), motion-mitigation strategies are of critical importance to ensure precise irradiation. Therefore, we compared applicability, effectiveness, reproducibility, and subjects' acceptance of enhanced deep-inspiration breath hold (eDIBH) with high-frequency percussive ventilation (HFPV) by MRI assessment within 1 month. Methods: Twenty-one healthy subjects (12 males/9 females; age: 49.5 ± 5.8 years; BMI: 24.7 ± 3.3 kg/m−2) performed two 1.5 T MRI scans in four visits at weekly intervals under eDIBH and HFPV conditions, accompanied by daily, home-based breath-hold training and spirometric assessments over a 3-week period. eDIBH consisted of 8-min 100% O2 breathing (3 min resting ventilation, 5 min controlled hyperventilation) prior to breath hold. HFPV was set at 200–250 pulses min−1 and 0.8–1.2 bar. Subjects' acceptance and preference were evaluated by questionnaire. To quantify inter- and intrafractional changes, a lung distance metric representing lung topography was computed for 10 reference points: a motion-invariant spinal cord and nine lung structure contours (LSCs: apex, carina, diaphragm, and six vessels as tumor surrogates distributed equally across the lung). To parameterize individual LSC localizability, measures of their spatial variabilities were introduced and lung volumes calculated by automated MRI analysis. Results: eDIBH increased breath-hold duration by > 100% up to 173 ± 73 s at visit 1, and to 217 ± 67 s after 3 weeks of home-based training at visit 4 (p < 0.001). Measures of vital capacity and lung volume remained constant over the 3-week period. Two vessels in the lower lung segment and the diaphragm yielded a two- to threefold improved positional stability with eDIBH, whereby absolute distance variability was significantly smaller for five LSCs; ≥70% of subjects showed significantly better intrafractional lung motion mitigation under reproducible conditions with eDIBH compared with HFPV with smaller ranges most apparent in the anterior-posterior and cranial-caudal directions. Approximately 80% of subjects preferred eDIBH over HFPV, with “less discomfort” named as most frequent reason. Conclusions: Both, eDIBH, and HFPV were well-tolerated. eDIBH duration was long enough to allow for potential PRT. Variability in lung volume was smaller and position of lung structures more precise with eDIBH. Subjects preferred eDIBH over HFPV. Thus, eDIBH is a very promising tool for lung tumor therapy with PRT, and further investigation of its applicability in patients is warranted.
Collapse
Affiliation(s)
- Frank Emert
- Center for Proton Therapy, Paul Scherrer Institute (PSI), Villigen, Switzerland
| | - John Missimer
- Center for Proton Therapy, Paul Scherrer Institute (PSI), Villigen, Switzerland
| | - Philipp A Eichenberger
- Exercise Physiology Lab, Department of Health Sciences and Technology, Institute of Human Movement Sciences and Sport, ETH Zurich, Zurich, Switzerland
| | - Marc Walser
- Center for Proton Therapy, Paul Scherrer Institute (PSI), Villigen, Switzerland
| | - Celina Gmür
- Exercise Physiology Lab, Department of Health Sciences and Technology, Institute of Human Movement Sciences and Sport, ETH Zurich, Zurich, Switzerland
| | - Antony J Lomax
- Center for Proton Therapy, Paul Scherrer Institute (PSI), Villigen, Switzerland.,Department of Physics, ETH Zurich, Zurich, Switzerland
| | - Damien C Weber
- Center for Proton Therapy, Paul Scherrer Institute (PSI), Villigen, Switzerland.,Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland.,Department of Radiation Oncology, University Hospital Bern, Bern, Switzerland
| | - Christina M Spengler
- Exercise Physiology Lab, Department of Health Sciences and Technology, Institute of Human Movement Sciences and Sport, ETH Zurich, Zurich, Switzerland.,Zurich Center for Integrative Human Physiology (ZIHP), University of Zurich, Zurich, Switzerland
| |
Collapse
|
7
|
Parkes MJ, De Neve W, Vakaet V, Heyes G, Jackson T, Delaney R, Kirby G, Green S, Kilby W, Cashmore J, Ghafoor Q, Clutton-Brock T. Safely achieving single prolonged breath-holds of > 5 minutes for radiotherapy in the prone, front crawl position. Br J Radiol 2021; 94:20210079. [PMID: 33914612 PMCID: PMC8173692 DOI: 10.1259/bjr.20210079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Breast cancer radiotherapy is increasingly delivered supine with multiple, short breath-holds. There may be heart and lung sparing advantages for locoregional breast cancer of both prone treatment and in a single breath-hold. We test here whether single prolonged breath-holds are possible in the prone, front crawl position. METHODS 19 healthy volunteers were trained to deliver supine, single prolonged breath-holds with pre-oxygenation and hypocapnia. We tested whether all could achieve the same durations in the prone, front crawl position. RESULTS 19 healthy volunteers achieved supine, single prolonged breath-holds for mean of 6.2 ± 0.3 min. All were able to hold safely for the same duration while prone (6.1 ± 0.2 min ns. by paired ANOVA). With prone, the increased weight on the chest did not impede chest inflation, nor the ability to hold air in the chest. Thus, the rate of chest deflation (mean anteroposterior deflation movement of three craniocaudally arranged surface markers on the spinal cord) was the same (1.2 ± 0.2, 2.0 ± 0.4 and 1.2 ± 0.4 mm/min) as found previously during supine prolonged breath-holds. No leakage of carbon dioxide or air was detectable into the facemask. CONCLUSION Single prolonged (>5 min) breath-holds are equally possible in the prone, front crawl position. ADVANCES IN KNOWLEDGE Prolonged breath-holds in the front crawl position are possible and have the same durations as in the supine position. Such training would therefore be feasible for some patients with breast cancer requiring loco-regional irradiation. It would have obvious advantages for hypofractionation.
Collapse
Affiliation(s)
- M J Parkes
- School of Sport, Exercise & Rehabilitation Sciences, Birmingham, UK.,National Institute for Health Research (NIHR)/Wellcome Trust Birmingham Clinical Research Facility, Birmingham, UK.,Hall Edwards Radiotherapy Group, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Wilfried De Neve
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Vincent Vakaet
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Geoffrey Heyes
- Hall Edwards Radiotherapy Group, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Timothy Jackson
- Hall Edwards Radiotherapy Group, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard Delaney
- Hall Edwards Radiotherapy Group, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Gavin Kirby
- Hall Edwards Radiotherapy Group, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Stuart Green
- Hall Edwards Radiotherapy Group, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Jason Cashmore
- Hall Edwards Radiotherapy Group, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Qamar Ghafoor
- Hall Edwards Radiotherapy Group, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Thomas Clutton-Brock
- National Institute for Health Research (NIHR)/Wellcome Trust Birmingham Clinical Research Facility, Birmingham, UK.,Department of Anaesthesia and Intensive Care Medicine, University of Birmingham andUniversity Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| |
Collapse
|
8
|
Vakaet V, Van Hulle H, Schoepen M, Van Caelenberg E, Van Greveling A, Holvoet J, Monten C, De Baerdemaeker L, De Neve W, Coppens M, Veldeman L. Prolonging deep inspiration breath-hold time to 3 min during radiotherapy, a simple solution. Clin Transl Radiat Oncol 2021; 28:10-16. [PMID: 33732910 PMCID: PMC7941008 DOI: 10.1016/j.ctro.2021.02.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 02/17/2021] [Accepted: 02/17/2021] [Indexed: 01/07/2023] Open
Abstract
A new protocol was developped to prolong deep inspiration breath-holds. Multiple prolonged breath-holds are achievable with minimal side effects. DIBH was prolonged to 3 min using HFNO and hyperventilation in breast cancer patients.
Background and purpose Deep inspiration breath-hold is an established technique to reduce heart dose during breast cancer radiotherapy. However, modern breast cancer radiotherapy techniques with lymph node irradiation often require long beam-on times of up to 5 min. Therefore, the combination with deep inspiration breath-hold (DIBH) becomes challenging. A simple support technique for longer duration deep inspiration breath-hold (L-DIBH), feasible for daily use at the radiotherapy department, is required to maximize heart sparing. Materials and methods At our department, a new protocol for multiple L-DIBH of at least 2 min and 30 s was developed on 32 healthy volunteers and validated on 8 breast cancer patients during radiotherapy treatment, using a pragmatic process of iterative development, including all major stakeholders. Each participant performed 12 L-DIBHs, on 4 different days. Different methods of pre-oxygenation and voluntary hyperventilation were tested, and scored on L-DIBH duration, ease of use, and comfort. Results Based on 384 L-DIBHs from 32 healthy volunteers, voluntary hyperventilation for 3 min whilst receiving high-flow nasal oxygen at 40 L/min was the most promising technique. During validation, the median L-DIBH duration in prone position of 8 breast cancer patients improved from 59 s without support to 3 min and 9 s using the technique (p < 0.001). Conclusion A new and simple L-DIBH protocol was developed feasible for daily use at the radiotherapy center.
Collapse
Affiliation(s)
- Vincent Vakaet
- Department of Human Structure and Repair, Ghent University, Belgium.,Department of Radiation Oncology, Ghent University Hospital, Belgium
| | - Hans Van Hulle
- Department of Human Structure and Repair, Ghent University, Belgium
| | - Max Schoepen
- Department of Human Structure and Repair, Ghent University, Belgium.,Department of Industrial Systems Engineering and Product Design, Kortrijk, Belgium
| | | | | | - Jeroen Holvoet
- Department of Radiation Oncology, Ghent University Hospital, Belgium
| | - Chris Monten
- Department of Human Structure and Repair, Ghent University, Belgium.,Department of Radiation Oncology, Ghent University Hospital, Belgium
| | - Luc De Baerdemaeker
- Department of Anesthesia, Ghent University Hospital, Belgium.,Department of Basic and Applied Medical Sciences, Ghent University, Belgium
| | - Wilfried De Neve
- Department of Human Structure and Repair, Ghent University, Belgium.,Department of Radiation Oncology, Ghent University Hospital, Belgium
| | - Marc Coppens
- Department of Anesthesia, Ghent University Hospital, Belgium.,Department of Basic and Applied Medical Sciences, Ghent University, Belgium
| | - Liv Veldeman
- Department of Human Structure and Repair, Ghent University, Belgium.,Department of Radiation Oncology, Ghent University Hospital, Belgium
| |
Collapse
|
9
|
Comparison of different methods for lung immobilization in an animal model. Radiother Oncol 2020; 150:151-158. [PMID: 32580000 DOI: 10.1016/j.radonc.2020.06.024] [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: 04/01/2020] [Revised: 05/28/2020] [Accepted: 06/17/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE Respiratory-induced motion introduces uncertainties in the delivery of dose in radiotherapy treatments. Various methods are used clinically, e.g. breath-holding, while there is limited experience with other methods such as apneic oxygenation and high frequency jet ventilation (HFJV). This study aims to compare the latter approaches for lung immobilization and their clinical impact on gas exchange in an animal model. MATERIALS AND METHODS Two radiopaque tumor surrogate markers (TSM) were placed in the central (cTSM) and peripheral (dTSM) regions of the lungs in 9 anesthetized and muscle relaxed pigs undergoing 3 ventilatory interventions (1) HFJV at rates of 200 (JV200), 300 (JV300) and 400 (JV400) min-1; (2) apnea at continuous positive airway pressure (CPAP) levels of 0, 8 and 16 cmH2O; (3) conventional mechanical ventilation (CMV) as reference mode. cTSM and dTSM were visualized using fluoroscopy and their coordinates were computed. The ventilatory pattern was registered, and oxygen and carbon dioxide (pCO2) partial pressures were measured. RESULTS The highest range of TSM motion, and ventilation was found during CMV, the lowest during apnea. During HFJV the amount of motion varied inversely with increasing frequency. The reduction of TSM motion at JV300, JV400 and all CPAP levels came at the cost of increased pCO2, however the relatively low frequency of 200 min-1 for HFJV was the only ventilatory setting that enabled adequate CO2 removal. CONCLUSION In this model, HFJV at 200 min-1 was the best compromise between immobilization and gas exchange for sessions of 10-min duration.
Collapse
|
10
|
Parkes MJ, Green S, Kilby W, Cashmore J, Ghafoor Q, Clutton-Brock TH. The feasibility, safety and optimization of multiple prolonged breath-holds for radiotherapy. Radiother Oncol 2019; 141:296-303. [PMID: 31540744 DOI: 10.1016/j.radonc.2019.06.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 05/15/2019] [Accepted: 06/11/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND & PURPOSE Multiple, short breath-holds are now used in single radiotherapy treatment sessions. Here we investigated the feasibility and safety of multiple prolonged breath-holds in a single session. We measured how long is a second breath-hold if we prematurely terminate a single, prolonged breath-hold of >5 min either by using a single breath of oxygen (O2), or by reintroducing preoxygenation and hypocapnia. We also investigated the feasibility and safety of undertaking 9 prolonged breath-holds in a row. MATERIALS & METHODS 30 healthy volunteers with no previous breath-holding experience were trained to perform single prolonged breath-holds safely. RESULTS Their mean single, prolonged breath-hold duration was 6.1 ± 0.3 se minutes (n = 30). In 18/18 subjects, premature termination (at 5.1 ± 0.2 min) with a single breath of 60% O2, enabled a 2nd safe breath-hold lasting 3.3 ± 0.2 min. In 18/18 subjects, premature termination at 5.3 ± 0.2 min) by reintroducing preoxygenation and hypocapnia, enabled a 2nd safe breath-hold lasting 5.8 ± 0.3 min. 17/17 subjects could safely perform 9 successive prolonged breath-holds, each terminated (at 4.3 ± 0.2 min) by reintroducing preoxygenation and hypocapnia for 3.1 ± 0.2 min. The 9th unconstrained breath-hold (mean of 6.0 ± 0.3 min) lasted as long as their single breath-hold. CONCLUSIONS Multiple prolonged breath-holds are possible and safe. In a ∼19 min treatment session, it would therefore be possible to have ∼13 min for radiotherapy treatment (3 breath-holds) and ∼6 min for setup and recovery. In a 65 min session, it would be possible to have 41 min for radiotherapy and 25 min for setup and recovery.
Collapse
Affiliation(s)
- Michael John Parkes
- School of Sport, Exercise & Rehabilitation Sciences, United Kingdom; National Institute for Health Research (NIHR)/Wellcome Trust Birmingham Clinical Research Facility, United Kingdom; Hall Edwards Radiotherapy Group, University Hospitals Birmingham NHS Foundation Trust, United Kingdom.
| | - Stuart Green
- Hall Edwards Radiotherapy Group, University Hospitals Birmingham NHS Foundation Trust, United Kingdom
| | | | - Jason Cashmore
- Hall Edwards Radiotherapy Group, University Hospitals Birmingham NHS Foundation Trust, United Kingdom
| | - Qamar Ghafoor
- Hall Edwards Radiotherapy Group, University Hospitals Birmingham NHS Foundation Trust, United Kingdom
| | - Thomas Henry Clutton-Brock
- National Institute for Health Research (NIHR)/Wellcome Trust Birmingham Clinical Research Facility, United Kingdom; Department of Anaesthesia and Intensive Care Medicine, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, United Kingdom
| |
Collapse
|
11
|
Lyons C, Callaghan M. Uses and mechanisms of apnoeic oxygenation: a narrative review. Anaesthesia 2019; 74:497-507. [DOI: 10.1111/anae.14565] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2018] [Indexed: 12/31/2022]
Affiliation(s)
- C. Lyons
- Department of Anaesthesia; Mater Misericordiae University Hospital; Dublin Ireland
| | - M. Callaghan
- Department of Anaesthesia; Galway University Hospitals; Galway Ireland
| |
Collapse
|
12
|
Parkes MJ, Green S, Stevens AM, Parveen S, Stephens R, Clutton-Brock TH. Safely prolonging single breath-holds to >5 min in patients with cancer; feasibility and applications for radiotherapy. Br J Radiol 2017; 89:20160194. [PMID: 27168468 PMCID: PMC5257330 DOI: 10.1259/bjr.20160194] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE Multiple, short and deep inspiratory breath-holds with air of approximately 20 s are now used in radiotherapy to reduce the influence of ventilatory motion and damage to healthy tissue. There may be further clinical advantages in delivering each treatment session in only one single, prolonged breath-hold. We have previously developed techniques enabling healthy subjects to breath-hold for 7 min. Here, we demonstrate their successful application in patients with cancer. METHODS 15 patients aged 37-74 years undergoing radiotherapy for breast cancer were trained to breath-hold safely with pre-oxygenation and mechanically induced hypocapnia under simulated radiotherapy treatment conditions. RESULTS The mean breath-hold duration was 5.3 ± 0.2 min. At breakpoint, all patients were normocapnic and normoxic [mean end-tidal partial pressure of carbon dioxide was 36 ± 1 standard error millimetre of mercury, (mmHg) and mean oxygen saturation was 100 ± 0 standard error %]. None were distressed, nor had gasping, dizziness or disturbed breathing in the post-breath-hold period. Mean blood pressure had risen significantly from 125 ± 3 to 166 ± 4 mmHg at breakpoint (without heart rate falling), but normalized within approximately 20 s of the breakpoint. During breath-holding, the mean linear anteroposterior displacement slope of the L breast marker was <2 mm min(-1). CONCLUSION Patients with cancer can be trained to breath-hold safely and under simulated radiotherapy treatment conditions for longer than the typical beam-on time of a single fraction. We discuss the important applications of this technique for radiotherapy. ADVANCES IN KNOWLEDGE We demonstrate for the first time a technique enabling patients with cancer to deliver safely a single prolonged breath-hold of >5 min (10 times longer than currently used in radiotherapy practice), under simulated radiotherapy treatment conditions.
Collapse
Affiliation(s)
- Michael J Parkes
- 1 School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK.,2 National Institute for Health Research (NIHR)/Wellcome Trust Birmingham Clinical Research Facility, Queen Elizabeth Hospital, Birmingham, UK
| | - Stuart Green
- 3 Hall Edwards Radiotherapy Group, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Andrea M Stevens
- 3 Hall Edwards Radiotherapy Group, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Sophia Parveen
- 3 Hall Edwards Radiotherapy Group, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Rebecca Stephens
- 3 Hall Edwards Radiotherapy Group, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Thomas H Clutton-Brock
- 2 National Institute for Health Research (NIHR)/Wellcome Trust Birmingham Clinical Research Facility, Queen Elizabeth Hospital, Birmingham, UK.,4 Department Anaesthesia and Intensive Care Medicine, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| |
Collapse
|
13
|
Parkes MJ, Green S, Stevens AM, Clutton-Brock TH. Assessing and ensuring patient safety during breath-holding for radiotherapy. Br J Radiol 2014; 87:20140454. [PMID: 25189121 PMCID: PMC4207152 DOI: 10.1259/bjr.20140454] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: While there is recent interest in using repeated deep inspiratory breath-holds, or prolonged single breath-holds, to improve radiotherapy delivery, breath-holding has risks. There are no published guidelines for monitoring patient safety, and there is little clinical awareness of the pronounced blood pressure rise and the potential for gradual asphyxia that occur during breath-holding. We describe the blood pressure rise during deep inspiratory breath-holding with air and test whether it can be abolished simply by pre-oxygenation and hypocapnia. Methods: We measured blood pressure, oxygen saturation (SpO2) and heart rate in 12 healthy, untrained subjects performing breath-holds. Results: Even for deep inspiratory breath-holds with air, the blood pressure rose progressively (e.g. mean systolic pressure rose from 133 ± 5 to 175 ± 8 mmHg at breakpoint, p < 0.005, and in two subjects, it reached 200 mmHg). Pre-oxygenation and hypocapnia prolonged breath-hold duration and prevented the development of asphyxia but failed to abolish the pressure rise. The pressure rise was not a function of breath-hold duration and was not signalled by any fall in heart rate (remaining at resting levels of 72 ± 2 beats per minute). Conclusion: Colleagues should be aware of the progressive blood pressure rise during deep inspiratory breath-holding that so far is not easily prevented. In breast cancer patients scheduled for breath-holds, we recommend routine screening for heart, cardiovascular, renal and cerebrovascular disease, routine monitoring of patient blood pressure and SpO2 during breath-holding and requesting patients to stop if systolic pressure rises consistently >180 mmHg and or SpO2 falls <94%. Advances in knowledge: There is recent interest in using deep inspiratory breath-holds, or prolonged single breath-holding techniques, to improve radiotherapy delivery. But there appears to be no clinical awareness of the risks to patients from breath-holding. We demonstrate the progressive blood pressure rise during deep inspiratory breath-holds with air, which we show cannot be prevented by the simple expedient of pre-oxygenation and hypocapnia. We propose patient screening and safety guidelines for monitoring both blood pressure and SpO2 during breath-holds and discuss their clinical implications.
Collapse
Affiliation(s)
- M J Parkes
- 1 National Institute for Health Research (NIHR)/Wellcome Trust Birmingham Clinical Research Facility, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | | | | |
Collapse
|