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Shah SN, Shah SS, Hosford-Skapof M, Shah SA. Salvage Radiosurgery for Recurrent Cardiac Sarcoma: A Case Report. Cureus 2023; 15:e44990. [PMID: 37822426 PMCID: PMC10564393 DOI: 10.7759/cureus.44990] [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: 06/23/2023] [Accepted: 09/09/2023] [Indexed: 10/13/2023] Open
Abstract
Primary cardiac sarcoma is a rare malignant tumor that arises from the cardiac myocardium. Surgical resection is the standard of care, and median survival ranges from 6 to 12 months. The role of salvage chemotherapy and radiation is not well defined. A 53-year-old female presented with acute congestive heart failure and underwent complete surgical resection of an undifferentiated pleomorphic sarcoma of the left atrium, followed by six cycles of adjuvant doxorubicin/hydroxydaunorubicin and ifosfamide. An MRI scan demonstrated an asymptomatic, 24 mm, recurrent atrial mass. The patient was treated with frameless robotic radiation therapy over three weeks. The tumor was treated with a dose of 72 Gy in 15 fractions to the 84% isodose line. A repeat cardiac MRI at four weeks showed in-field local progression with greater protrusion into the left atrium and invasion of the left ventricle. The patient therefore elected to proceed with salvage single-fraction frameless robotic radiosurgery. 25 Gy in one fraction was prescribed to the 76% isodose line. She tolerated treatment well without any acute toxicity and was subsequently treated with a variety of chemotherapy regimens, including tyrosine kinase inhibitors (TKIs) and immunotherapy. Unfortunately, the patient relapsed with metastases in the spine and pelvis. She underwent palliative radiation therapy at multiple bony sites with a partial response. She resumed chemotherapy treatment with TKIs but passed away due to septic shock without evidence of local failure. Fractionated SBRT was ineffective at controlling our patient's cardiac sarcoma. Our patient demonstrated local control of disease at 12 months after salvage of 25 Gy in one fraction of radiosurgery without any evidence of cardiac toxicity. High-dose single-fraction radiosurgery is a reasonable palliative option for long-term local control of unresectable cardiac sarcomas.
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Affiliation(s)
- Sophia N Shah
- Radiation Oncology, Christiana Care Health System, Newark, USA
| | - Sohan S Shah
- Radiation Oncology, Christiana Care Health System, Newark, USA
| | | | - Sunjay A Shah
- Radiation Oncology, Christiana Care Health System, Newark, USA
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Franzetti J, Volpe S, Catto V, Conte E, Piccolo C, Pepa M, Piperno G, Camarda AM, Cattani F, Andreini D, Tondo C, Jereczek-Fossa BA, Carbucicchio C. Stereotactic Radiotherapy Ablation and Atrial Fibrillation: Technical Issues and Clinical Expectations Derived From a Systematic Review. Front Cardiovasc Med 2022; 9:849201. [PMID: 35592393 PMCID: PMC9110686 DOI: 10.3389/fcvm.2022.849201] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 03/22/2022] [Indexed: 11/13/2022] Open
Abstract
Aim The purpose of this study is to collect available evidence on the feasibility and efficacy of stereotactic arrhythmia radio ablation (STAR), including both photon radiotherapy (XRT) and particle beam therapy (PBT), in the treatment of atrial fibrillation (AF), and to provide cardiologists and radiation oncologists with a practical overview on this topic. Methods Three hundred and thirty-five articles were identified up to November 2021 according to preferred reporting items for systematic reviews and meta-analyses criteria; preclinical and clinical studies were included without data restrictions or language limitations. Selected works were analyzed for comparing target selection, treatment plan details, and the accelerator employed, addressing workup modalities, acute and long-term side-effects, and efficacy, defined either by the presence of scar or by the absence of AF recurrence. Results Twenty-one works published between 2010 and 2021 were included. Seventeen studies concerned XRT, three PBT, and one involved both. Nine studies (1 in silico and 8 in vivo; doses ranging from 15 to 40 Gy) comprised a total of 59 animals, 12 (8 in silico, 4 in vivo; doses ranging from 16 to 50 Gy) focused on humans, with 9 patients undergoing STAR: average follow-up duration was 5 and 6 months, respectively. Data analysis supported efficacy of the treatment in the preclinical setting, whereas in the context of clinical studies the main favorable finding consisted in the detection of electrical scar in 4/4 patients undergoing specific evaluation; the minimum dose for efficacy was 25 Gy in both humans and animals. No acute complication was recorded; severe side-effects related to the long-term were observed only for very high STAR doses in 2 animals. Significant variability was evidenced among studies in the definition of target volume and doses, and in the management of respiratory and cardiac target motion. Conclusion STAR is an innovative non-invasive procedure already applied for experimental treatment of ventricular arrhythmias. Particular attention must be paid to safety, rather than efficacy of STAR, given the benign nature of AF. Uncertainties persist, mainly regarding the definition of the treatment plan and the role of the target motion. In this setting, more information about the toxicity profile of this new approach is compulsory before applying STAR to AF in clinical practice.
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Affiliation(s)
- Jessica Franzetti
- Department of Radiation Oncology, European Institute of Oncology (IEO) IRCCS, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Stefania Volpe
- Department of Radiation Oncology, European Institute of Oncology (IEO) IRCCS, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
- *Correspondence: Stefania Volpe, , orcid.org/0000-0003-0498-2964
| | - Valentina Catto
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino IRCCS, Milan, Italy
- Department of Electronics, Information and Biomedical Engineering, Politecnico di Milano, Milan, Italy
| | - Edoardo Conte
- Cardiovascular Computed Tomography and Radiology Unit, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Consiglia Piccolo
- Unit of Medical Physics, European Institute of Oncology (IEO) IRCCS, Milan, Italy
| | - Matteo Pepa
- Department of Radiation Oncology, European Institute of Oncology (IEO) IRCCS, Milan, Italy
| | - Gaia Piperno
- Department of Radiation Oncology, European Institute of Oncology (IEO) IRCCS, Milan, Italy
| | - Anna Maria Camarda
- Department of Radiation Oncology, European Institute of Oncology (IEO) IRCCS, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Federica Cattani
- Unit of Medical Physics, European Institute of Oncology (IEO) IRCCS, Milan, Italy
| | - Daniele Andreini
- Cardiovascular Computed Tomography and Radiology Unit, Centro Cardiologico Monzino IRCCS, Milan, Italy
- Department of Biomedical and Clinical Sciences “Luigi Sacco”, University of Milan, Milan, Italy
| | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Barbara Alicja Jereczek-Fossa
- Department of Radiation Oncology, European Institute of Oncology (IEO) IRCCS, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Corrado Carbucicchio
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino IRCCS, Milan, Italy
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Ren XY, He PK, Gao XS, Zhao ZL, Zhao B, Bai Y, Liu SW, Li K, Qin SB, Ma MW, Zhou J, Rong Y. Dosimetric feasibility of stereotactic ablative radiotherapy in pulmonary vein isolation for atrial fibrillation using intensity-modulated proton therapy. J Appl Clin Med Phys 2021; 22:79-88. [PMID: 33817981 PMCID: PMC8130224 DOI: 10.1002/acm2.13239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 03/03/2021] [Accepted: 03/06/2021] [Indexed: 12/25/2022] Open
Abstract
Purpose To evaluate dosimetric properties of intensity‐modulated proton therapy (IMPT) for simulated treatment planning in patients with atrial fibrillation (AF) targeting left atrial‐pulmonary vein junction (LA‐PVJ), in comparison with volumetric‐modulated arc therapy (VMAT) and helical tomotherapy (TOMO). Methods Ten thoracic 4D‐CT scans with respiratory motion and one with cardiac motion were used for the study. Ten respiratory 4D‐CTs were planned with VMAT, TOMO, and IMPT for simulated AF. Targets at the LA‐PVJ were defined as wide‐area circumferential ablation line. A single fraction of 25 Gy was prescribed to all plans. The interplay effects from cardiac motion were evaluated based on the cardiac 4D‐CT scan. Dose‐volume histograms (DVHs) of the ITV and normal tissues were compared. Statistical analysis was evaluated via one‐way Repeated‐Measures ANOVA and Friedman’s test with Bonferroni’s multiple comparisons test. Results The median volume of ITV was 8.72cc. All plans had adequate target coverage (V23.75Gy ≥ 99%). Compared with VMAT and TOMO, IMPT resulted in significantly lower dose of most normal tissues. For VMAT, TOMO, and IMPT plans, Dmean of the whole heart was 5.52 ± 0.90 Gy, 5.89 ± 0.78 Gy, and 3.01 ± 0.57 Gy (P < 0.001), mean dose of pericardium was 4.74 ± 0.76 Gy, 4.98 ± 0.62 Gy, and 2.59 ± 0.44 Gy (P < 0.001), and D0.03cc of left circumflex artery (LCX) was 13.96 ± 5.45 Gy, 14.34 ± 5.91 Gy, and 8.43 ± 7.24 Gy (P < 0.001), respectively. However, no significant advantage for one technique over the others was observed when examining the D0.03cc of esophagus and main bronchi. Conclusions IMPT targeting LA‐PVJ for patients with AF has high potential to reduce dose to surrounding tissues compared to VMAT or TOMO. Motion mitigation techniques are critical for a particle‐therapy approach.
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Affiliation(s)
- Xue-Ying Ren
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Peng-Kang He
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Xian-Shu Gao
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Zhi-Lei Zhao
- Department of Radiation Oncology, Yizhou International Proton Therapy Medical Center, Hebei, China
| | - Bo Zhao
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Yun Bai
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Si-Wei Liu
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Kang Li
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Shang-Bin Qin
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Ming-Wei Ma
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Jing Zhou
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Yi Rong
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
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Corradini S, von Bestenbostel R, Romano A, Curta A, Di Gioia D, Placidi L, Niyazi M, Boldrini L. MR-guided stereotactic body radiation therapy for primary cardiac sarcomas. Radiat Oncol 2021; 16:60. [PMID: 33771179 PMCID: PMC7995725 DOI: 10.1186/s13014-021-01791-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 03/17/2021] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Primary cardiac tumors are an extremely rare disease with limited prognosis. The treatment of choice is surgery. Other treatment options include chemotherapy and radiation therapy, which historically represented a palliative approach in patients who were not eligible for surgery. The development of hybrid MR-guided radiation therapy makes it possible to better visualize cardiac lesions and to apply high doses per fraction in sensible organs such as the heart. CASE PRESENTATION Patients affected by inoperable primary cardiac sarcomas and treated at two different institutions were considered for this analysis and retrospectively analyzed. All patients were treated using a 0.35 T hybrid MR Linac system (MRIdian, ViewRay Inc., Mountain View, CA). In the present study we investigated the feasibility, early outcome and toxicity of MR-guided RT in primary cardiac sarcomas. Four consecutive non-metastasized patients who were treated between 05-09/2020 were analyzed. The cardiac sarcomas were mostly located in the right atrium (50%) and one patient presented with 3 epicardial lesions. All patients received MRgRT as a salvage treatment for recurrent cardiac sarcoma after initial surgery, after a mean interval of 12 months (range 1-29 months). Regarding the treatment characteristics, the mean GTV size was 22.9 cc (range 2.5-56.9 cc) and patients were treated with a mean GTV dose of 38.9 Gy (range 30.1-41.1 Gy) in 5 fractions. Regarding feasibility, all treatments were completed as planned and all patients tolerated the treatment very well and showed only mild grade 1 or 2 symptoms like fatigue, dyspnea or mild chest pain at early follow-up. CONCLUSION To the best of our knowledge, in this retrospective analysis we present the first and largest series of patients presenting with primary cardiac sarcomas treated with online adaptive MRgRT. However, further studies are needed to evaluate the impact of this new methodology on the outcome of this very rare disease.
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Affiliation(s)
- Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | | | - Angela Romano
- Department of Bioimaging, Radiation Oncology and Hematology, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy.
| | - Adrian Curta
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Dorit Di Gioia
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Lorenzo Placidi
- Department of Bioimaging, Radiation Oncology and Hematology, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Luca Boldrini
- Department of Bioimaging, Radiation Oncology and Hematology, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
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Sim AJ, Palm RF, DeLozier KB, Feygelman V, Latifi K, Redler G, Washington IR, Wuthrick EJ, Rosenberg SA. MR-guided stereotactic body radiation therapy for intracardiac and pericardial metastases. Clin Transl Radiat Oncol 2020; 25:102-106. [PMID: 33204858 PMCID: PMC7653008 DOI: 10.1016/j.ctro.2020.10.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/25/2020] [Accepted: 10/26/2020] [Indexed: 02/08/2023] Open
Abstract
Radiation is not typical in the standard of care for cardiac metastases. MR-guided radiation uses real-time imaging and offers better soft tissue contrast. Real-time MR-guidance allows for safe high dose radiation to cardiac metastases. MR-guided stereotactic radiation can improve symptoms without acute toxicity.
Aims To assess the safety and efficacy of MR-guided stereotactic body radiation therapy (MRgSBRT) for cardiac metastases. Materials/methods This single institution retrospective analysis evaluated our experience with MRgSBRT for cardiac metastases. Response rate was compared between pre-RT and post-RT imaging. Symptomatic changes were also tracked and documented. Results Between 4/2019 and 3/2020, five patients with cardiac metastases (4 intracardiac and 1 pericardial) were treated with MRgSBRT. Median age at treatment was 73 years (range 64–80) and two patients had pre-existing cardiac disease. Histologies included melanoma and breast adenocarcinoma. Median lesion diameter was 2 cm (range 1.96–5.8 cm). Three patients were symptomatic, one of whom had pulmonary hypertension and RV enlargement. Another patient had an asymptomatic arrythmia. Median PTV prescribed dose was 40 Gy (range 40–50 Gy) and delivered in five fractions on nonconsecutive days. Median PTV volume was 53.4 cc (range 8.7–116.6 cc) and median coverage was 95% (range 84.1–100%). A uniform 3 mm margin was used for real-time gating, allowing a median 7% (range 5–10%) pixel excursion tolerance. Median follow-up was 4.7 months (range 0.9–12.3). Two patients exhibited stable disease, two had a partial response and one exhibited a complete response. All symptomatic patients experienced some relief. There were no acute adverse events, however, one patient without prior cardiac disease developed atrial fibrillation 6 months after treatment. Two patients died of causes unrelated to cardiac MRgSBRT. Conclusion In this largest known series of cardiac metastasis MRgSBRT, real-time image guidance enables safe treatment resulting in good response with improving presenting symptoms without acute adverse events.
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Affiliation(s)
- Austin J Sim
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Russell F Palm
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Kirby B DeLozier
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Vladimir Feygelman
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Kujtim Latifi
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Gage Redler
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Iman R Washington
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Evan J Wuthrick
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Stephen A Rosenberg
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
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Qian PC, Azpiri JR, Assad J, Gonzales Aceves EN, Cardona Ibarra CE, de la Pena C, Hinojosa M, Wong D, Fogarty T, Maguire P, Jack A, Gardner EA, Zei PC. Noninvasive stereotactic radioablation for the treatment of atrial fibrillation: First-in-man experience. J Arrhythm 2020; 36:67-74. [PMID: 32071622 PMCID: PMC7011819 DOI: 10.1002/joa3.12283] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 11/05/2019] [Accepted: 11/13/2019] [Indexed: 01/31/2023] Open
Abstract
PURPOSE Catheter ablation is an effective therapy for atrial fibrillation (AF). However, risks remain, and improved efficacy is desired. Stereotactic body radiotherapy (SBRT) is a well-established therapy used to noninvasively treat malignancies and functional disorders with precision. We evaluated the feasibility of stereotactic radioablation for treating paroxysmal AF. METHODS Two patients with drug-refractory paroxysmal AF underwent pulmonary vein isolation with SBRT. After placement of a percutaneous active fixation temporary pacing lead tracking fiducial, computed tomography (CT) angiography was performed to define left atrial anatomy. A tailored planning treatment volume was created to deliver contiguous linear ablations to isolate the pulmonary veins and posterior wall. Patients were treated on an outpatient basis in the radioablation suite. Clinical follow-up was performed through at least 24 months after therapy. RESULTS Both patients successfully underwent SBRT planning and treatment without significant early or long-term side effects up to 48 months of follow-up. One patient had AF recurrence after 6 months free of arrhythmia, while the second patient remains free of AF after 24 months with fibrosis detected on MRI scan consistent with the ablation lesion set. An incidentally noted small pericardial effusion occurred in one patient. CONCLUSION Stereotactic radioablation may be feasible for the treatment of drug-refractory AF. Further evaluation is warranted.
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Affiliation(s)
- Pierre C. Qian
- Division of Cardiovascular MedicineBrigham and Women's HospitalBostonMAUSA
| | - Jose R. Azpiri
- Department of CardiologyChristus HospitalMonterreyMexico
| | - Jose Assad
- Department of CardiologyChristus HospitalMonterreyMexico
| | | | | | | | - Miguel Hinojosa
- Department of Radiation OncologyChristus HospitalMonterreyMexico
| | | | | | | | | | | | - Paul C. Zei
- Division of Cardiovascular MedicineBrigham and Women's HospitalBostonMAUSA
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7
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Zei PC, Wong D, Gardner E, Fogarty T, Maguire P. Safety and efficacy of stereotactic radioablation targeting pulmonary vein tissues in an experimental model. Heart Rhythm 2018; 15:1420-1427. [DOI: 10.1016/j.hrthm.2018.04.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Indexed: 11/25/2022]
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Abstract
Purpose of Review Stereotactic radioablation is a commonly utilized technology to noninvasively treat solid tumors with precision and efficacy. Using a robotic arm mounted delivery system, multiple low-dose ionizing radiation beams are delivered from multiple angles, concentrating ablative energy at the target tissue. Recently, this technology has been evaluated for treatment of cardiac arrhythmias. This review will present the basic underlying principles, proof-of-principle studies, and clinical experience with stereotactic arrhythmia radioablation. Recent Findings Most recently, stereotactic radioablation has been used to safely and effectively treat a limited number of patients with malignant arrhythmias, including ventricular tachycardia (VT) and atrial fibrillation (AF). Treatment protocols, outcomes, ongoing studies, and future directions will be discussed. Summary Stereotactic radioablation is a well-established technology that has been shown to be a safe and effective therapy for patients with drug-refractory cardiac arrhythmias, including VT and AF. Further clinical evaluation to define safety and efficacy in larger populations of patients is needed.
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Affiliation(s)
- Paul C Zei
- Department of Medicine, Electrophysiology Section, Brigham and Women's Hospital, 70 Francis Street, Shapiro Building - Room 05088, Boston, MA, 02115, USA.
| | - Scott Soltys
- Department of Radiation Oncology, Stanford University, Stanford, CA, USA
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Blanck O, Ipsen S, Chan MK, Bauer R, Kerl M, Hunold P, Jacobi V, Bruder R, Schweikard A, Rades D, Vogl TJ, Kleine P, Bode F, Dunst J. Treatment Planning Considerations for Robotic Guided Cardiac Radiosurgery for Atrial Fibrillation. Cureus 2016; 8:e705. [PMID: 27588226 PMCID: PMC4999353 DOI: 10.7759/cureus.705] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Purpose Robotic guided stereotactic radiosurgery has recently been investigated for the treatment of atrial fibrillation (AF). Before moving into human treatments, multiple implications for treatment planning given a potential target tracking approach have to be considered. Materials & Methods Theoretical AF radiosurgery treatment plans for twenty-four patients were generated for baseline comparison. Eighteen patients were investigated under ideal tracking conditions, twelve patients under regional dose rate (RDR = applied dose over a certain time window) optimized conditions (beam delivery sequence sorting according to regional beam targeting), four patients under ultrasound tracking conditions (beam block of the ultrasound probe) and four patients with temporary single fiducial tracking conditions (differential surrogate-to-target respiratory and cardiac motion). Results With currently known guidelines on dose limitations of critical structures, treatment planning for AF radiosurgery with 25 Gy under ideal tracking conditions with a 3 mm safety margin may only be feasible in less than 40% of the patients due to the unfavorable esophagus and bronchial tree location relative to the left atrial antrum (target area). Beam delivery sequence sorting showed a large increase in RDR coverage (% of voxels having a larger dose rate for a given time window) of 10.8-92.4% (median, 38.0%) for a 40-50 min time window, which may be significant for non-malignant targets. For ultrasound tracking, blocking beams through the ultrasound probe was found to have no visible impact on plan quality given previous optimal ultrasound window estimation for the planning CT. For fiducial tracking in the right atrial septum, the differential motion may reduce target coverage by up to -24.9% which could be reduced to a median of -0.8% (maximum, -12.0%) by using 4D dose optimization. The cardiac motion was also found to have an impact on the dose distribution, at the anterior left atrial wall; however, the results need to be verified. Conclusion Robotic AF radiosurgery with 25 Gy may be feasible in a subgroup of patients under ideal tracking conditions. Ultrasound tracking was found to have the lowest impact on treatment planning and given its real-time imaging capability should be considered for AF robotic radiosurgery. Nevertheless, advanced treatment planning using RDR or 4D respiratory and cardiac dose optimization may be still advised despite using ideal tracking methods.
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Affiliation(s)
- Oliver Blanck
- Department for Radiation Oncology, University Medical Center Schleswig-Holstein, Campus Kiel, Germany ; Saphir Radiosurgery Center, Frankfurt and Güstrow, Germany
| | - Svenja Ipsen
- Robotics and Cognitive Systems, University of Lübeck
| | - Mark K Chan
- Department for Radiation Oncology, University Medical Center Schleswig-Holstein, Campus Kiel, Germany ; Department for Radiation Oncology, Tuen Mun Hospital, Hong Kong, Hong Kong
| | - Ralf Bauer
- Institute for Diagnostics and Interventional Radiology, University Clinic Frankfurt, Germany ; Department for Radiology and Nuclear Medicine, Kantonsspital St. Gallen, Switzerland
| | - Matthias Kerl
- Institute for Diagnostics and Interventional Radiology, University Clinic Frankfurt, Germany ; Radiology, Darmstadt, Germany
| | - Peter Hunold
- Clinic for Radiology and Nuclear Medicine, University Medical Center Schleswig-Holstein, Campus Lübeck, Germany
| | - Volkmar Jacobi
- Institute for Diagnostics and Interventional Radiology, University Clinic Frankfurt, Germany
| | - Ralf Bruder
- Institute for Robotics and Cognitive Systems, University of Lubeck
| | - Achim Schweikard
- Institute for Robotics and Cognitive Systems, University of Luebeck, Institute for Robotics and Cognitive Systems, University of Lubeck
| | - Dirk Rades
- Department for Radiation Oncology, University Medical Center Schleswig-Holstein, Campus Lübeck, Germany
| | - Thomas J Vogl
- Institute for Diagnostics and Interventional Radiology, University Clinic Frankfurt, Germany
| | - Peter Kleine
- Department for Thoracic, Cardiac and Thoracic Vascular Surgery, University Clinic Frankfurt, Germany
| | - Frank Bode
- Cardiology Department, Sana Clinic Oldenburg in Holstein
| | - Jürgen Dunst
- Department for Radiation Oncology, University Medical Center Schleswig-Holstein, Campus Kiel, Germany ; Department for Radiation Oncology, University Medical Center Copenhagen, Denmark
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Wang L, Fahimian B, Soltys SG, Zei P, Lo A, Gardner EA, Maguire PJ, Loo BW. Stereotactic Arrhythmia Radioablation (STAR) of Ventricular Tachycardia: A Treatment Planning Study. Cureus 2016; 8:e694. [PMID: 27570715 PMCID: PMC4996541 DOI: 10.7759/cureus.694] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Purpose The first stereotactic arrhythmia radioablation (STAR) of ventricular tachycardia (VT) was delivered at Stanford on a robotic radiosurgery system (CyberKnife® G4) in 2012. The results warranted further investigation of this treatment. Here we compare dosimetrically three possible treatment delivery platforms for STAR. Methods The anatomy and target volume of the first treated patient were used for this study. A dose of 25 Gy in one fraction was prescribed to the planning target volume (PTV). Treatment plans were created on three treatment platforms: CyberKnife® G4 system with Iris collimator (Multiplan, V. 4.6)(Plan #1), CyberKnife® M6 system with InCise 2TM multileaf collimator (Multiplan V. 5.3)(Plan #2) and Varian TrueBeamTM STx with HD 120TM MLC and 10MV flattening filter free (FFF) beam (Eclipse planning system, V.11) (Plan #3 coplanar and #4 noncoplanar VMAT plans). The four plans were compared by prescription isodose line, plan conformity index, dose gradient, as well as dose to the nearby critical structures. To assess the delivery efficiency, planned monitor units (MU) and estimated treatment time were evaluated. Results Plans #1-4 delivered 25 Gy to the PTV to the 75.0%, 83.0%, 84.3%, and 84.9% isodose lines and with conformity indices of 1.19, 1.16, 1.05, and 1.05, respectively. The dose gradients for plans #1-4 were 3.62, 3.42, 3.93, and 3.73 with the CyberKnife® MLC plan (Plan #2) the best, and the TrueBeamTM STx co-planar plan (Plan #3) the worst. The dose to nearby critical structures (lung, stomach, bowel, and esophagus) were all well within tolerance. The MUs for plans #1-4 were 27671, 16522, 6275, and 6004 for an estimated total-treatment-time/beam-delivery-time of 99/69, 65/35, 37/7, and 56/6 minutes, respectively, under the assumption of 30 minutes pretreatment setup time. For VMAT gated delivery, a 40% duty cycle, 2400MU/minute dose rate, and an extra 10 minutes per extra arc were assumed. Conclusion Clinically acceptable plans were created with all three platforms. Plans with MLC were considerably more efficient in MU. CyberKnife® M6 with InCise 2TM collimator provided the most conformal plan (steepest dose drop-off) with significantly reduced MU and treatment time. VMAT plans were most efficient in MU and delivery time. Fluoroscopic image guidance removes the need for additional fiducial marker placement; however, benefits may be moderated by worse dose gradient and more operator-dependent motion management by gated delivery.
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Affiliation(s)
- Lei Wang
- Department of Radiation Oncology, Stanford University School of Medicine
| | - Benjamin Fahimian
- Department of Radiation Oncology, Stanford University School of Medicine
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford University School of Medicine
| | - Paul Zei
- Cardiology, Stanford University School of Medicine
| | - Anthony Lo
- Department of Radiation Oncology, Stanford University School of Medicine
| | | | | | - Billy W Loo
- Department of Radiation Oncology, Stanford University School of Medicine ; Stanford Cancer Institute, Stanford University School of Medicine
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Loo BW, Soltys SG, Wang L, Lo A, Fahimian BP, Iagaru A, Norton L, Shan X, Gardner E, Fogarty T, Maguire P, Al-Ahmad A, Zei P. Stereotactic Ablative Radiotherapy for the Treatment of Refractory Cardiac Ventricular Arrhythmia. Circ Arrhythm Electrophysiol 2015; 8:748-50. [DOI: 10.1161/circep.115.002765] [Citation(s) in RCA: 115] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Billy W. Loo
- From the Department of Radiation Oncology (B.W.L., S.G.S., L.W., A.L., B.P.F., X.S.), Stanford Cancer Institute (B.W.L., S.G.S.), Department of Radiology, Division of Nuclear Medicine and Molecular Imaging (A.I.), and Department of Medicine (Cardiac Electrophysiology) (L.N., P.Z.), Stanford University School of Medicine, Stanford, CA; Cardiac Electrophysiology, Texas Cardiac Arrhythmia Institute, Austin, TX (A.A.-A.); and Department of Medical Affairs, CyberHeart, Inc., Portola Valley, CA (E.G., T.F
| | - Scott G. Soltys
- From the Department of Radiation Oncology (B.W.L., S.G.S., L.W., A.L., B.P.F., X.S.), Stanford Cancer Institute (B.W.L., S.G.S.), Department of Radiology, Division of Nuclear Medicine and Molecular Imaging (A.I.), and Department of Medicine (Cardiac Electrophysiology) (L.N., P.Z.), Stanford University School of Medicine, Stanford, CA; Cardiac Electrophysiology, Texas Cardiac Arrhythmia Institute, Austin, TX (A.A.-A.); and Department of Medical Affairs, CyberHeart, Inc., Portola Valley, CA (E.G., T.F
| | - Lei Wang
- From the Department of Radiation Oncology (B.W.L., S.G.S., L.W., A.L., B.P.F., X.S.), Stanford Cancer Institute (B.W.L., S.G.S.), Department of Radiology, Division of Nuclear Medicine and Molecular Imaging (A.I.), and Department of Medicine (Cardiac Electrophysiology) (L.N., P.Z.), Stanford University School of Medicine, Stanford, CA; Cardiac Electrophysiology, Texas Cardiac Arrhythmia Institute, Austin, TX (A.A.-A.); and Department of Medical Affairs, CyberHeart, Inc., Portola Valley, CA (E.G., T.F
| | - Anthony Lo
- From the Department of Radiation Oncology (B.W.L., S.G.S., L.W., A.L., B.P.F., X.S.), Stanford Cancer Institute (B.W.L., S.G.S.), Department of Radiology, Division of Nuclear Medicine and Molecular Imaging (A.I.), and Department of Medicine (Cardiac Electrophysiology) (L.N., P.Z.), Stanford University School of Medicine, Stanford, CA; Cardiac Electrophysiology, Texas Cardiac Arrhythmia Institute, Austin, TX (A.A.-A.); and Department of Medical Affairs, CyberHeart, Inc., Portola Valley, CA (E.G., T.F
| | - Benjamin P. Fahimian
- From the Department of Radiation Oncology (B.W.L., S.G.S., L.W., A.L., B.P.F., X.S.), Stanford Cancer Institute (B.W.L., S.G.S.), Department of Radiology, Division of Nuclear Medicine and Molecular Imaging (A.I.), and Department of Medicine (Cardiac Electrophysiology) (L.N., P.Z.), Stanford University School of Medicine, Stanford, CA; Cardiac Electrophysiology, Texas Cardiac Arrhythmia Institute, Austin, TX (A.A.-A.); and Department of Medical Affairs, CyberHeart, Inc., Portola Valley, CA (E.G., T.F
| | - Andrei Iagaru
- From the Department of Radiation Oncology (B.W.L., S.G.S., L.W., A.L., B.P.F., X.S.), Stanford Cancer Institute (B.W.L., S.G.S.), Department of Radiology, Division of Nuclear Medicine and Molecular Imaging (A.I.), and Department of Medicine (Cardiac Electrophysiology) (L.N., P.Z.), Stanford University School of Medicine, Stanford, CA; Cardiac Electrophysiology, Texas Cardiac Arrhythmia Institute, Austin, TX (A.A.-A.); and Department of Medical Affairs, CyberHeart, Inc., Portola Valley, CA (E.G., T.F
| | - Linda Norton
- From the Department of Radiation Oncology (B.W.L., S.G.S., L.W., A.L., B.P.F., X.S.), Stanford Cancer Institute (B.W.L., S.G.S.), Department of Radiology, Division of Nuclear Medicine and Molecular Imaging (A.I.), and Department of Medicine (Cardiac Electrophysiology) (L.N., P.Z.), Stanford University School of Medicine, Stanford, CA; Cardiac Electrophysiology, Texas Cardiac Arrhythmia Institute, Austin, TX (A.A.-A.); and Department of Medical Affairs, CyberHeart, Inc., Portola Valley, CA (E.G., T.F
| | - Xin Shan
- From the Department of Radiation Oncology (B.W.L., S.G.S., L.W., A.L., B.P.F., X.S.), Stanford Cancer Institute (B.W.L., S.G.S.), Department of Radiology, Division of Nuclear Medicine and Molecular Imaging (A.I.), and Department of Medicine (Cardiac Electrophysiology) (L.N., P.Z.), Stanford University School of Medicine, Stanford, CA; Cardiac Electrophysiology, Texas Cardiac Arrhythmia Institute, Austin, TX (A.A.-A.); and Department of Medical Affairs, CyberHeart, Inc., Portola Valley, CA (E.G., T.F
| | - Edward Gardner
- From the Department of Radiation Oncology (B.W.L., S.G.S., L.W., A.L., B.P.F., X.S.), Stanford Cancer Institute (B.W.L., S.G.S.), Department of Radiology, Division of Nuclear Medicine and Molecular Imaging (A.I.), and Department of Medicine (Cardiac Electrophysiology) (L.N., P.Z.), Stanford University School of Medicine, Stanford, CA; Cardiac Electrophysiology, Texas Cardiac Arrhythmia Institute, Austin, TX (A.A.-A.); and Department of Medical Affairs, CyberHeart, Inc., Portola Valley, CA (E.G., T.F
| | - Thomas Fogarty
- From the Department of Radiation Oncology (B.W.L., S.G.S., L.W., A.L., B.P.F., X.S.), Stanford Cancer Institute (B.W.L., S.G.S.), Department of Radiology, Division of Nuclear Medicine and Molecular Imaging (A.I.), and Department of Medicine (Cardiac Electrophysiology) (L.N., P.Z.), Stanford University School of Medicine, Stanford, CA; Cardiac Electrophysiology, Texas Cardiac Arrhythmia Institute, Austin, TX (A.A.-A.); and Department of Medical Affairs, CyberHeart, Inc., Portola Valley, CA (E.G., T.F
| | - Patrick Maguire
- From the Department of Radiation Oncology (B.W.L., S.G.S., L.W., A.L., B.P.F., X.S.), Stanford Cancer Institute (B.W.L., S.G.S.), Department of Radiology, Division of Nuclear Medicine and Molecular Imaging (A.I.), and Department of Medicine (Cardiac Electrophysiology) (L.N., P.Z.), Stanford University School of Medicine, Stanford, CA; Cardiac Electrophysiology, Texas Cardiac Arrhythmia Institute, Austin, TX (A.A.-A.); and Department of Medical Affairs, CyberHeart, Inc., Portola Valley, CA (E.G., T.F
| | - Amin Al-Ahmad
- From the Department of Radiation Oncology (B.W.L., S.G.S., L.W., A.L., B.P.F., X.S.), Stanford Cancer Institute (B.W.L., S.G.S.), Department of Radiology, Division of Nuclear Medicine and Molecular Imaging (A.I.), and Department of Medicine (Cardiac Electrophysiology) (L.N., P.Z.), Stanford University School of Medicine, Stanford, CA; Cardiac Electrophysiology, Texas Cardiac Arrhythmia Institute, Austin, TX (A.A.-A.); and Department of Medical Affairs, CyberHeart, Inc., Portola Valley, CA (E.G., T.F
| | - Paul Zei
- From the Department of Radiation Oncology (B.W.L., S.G.S., L.W., A.L., B.P.F., X.S.), Stanford Cancer Institute (B.W.L., S.G.S.), Department of Radiology, Division of Nuclear Medicine and Molecular Imaging (A.I.), and Department of Medicine (Cardiac Electrophysiology) (L.N., P.Z.), Stanford University School of Medicine, Stanford, CA; Cardiac Electrophysiology, Texas Cardiac Arrhythmia Institute, Austin, TX (A.A.-A.); and Department of Medical Affairs, CyberHeart, Inc., Portola Valley, CA (E.G., T.F
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Stereotactic Body Radiotherapy with Cyberknife for Cardiac Malignancies. TUMORI JOURNAL 2015; 101:294-7. [DOI: 10.5301/tj.5000280] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2014] [Indexed: 12/31/2022]
Abstract
Aims and Background Radiobiological and technical considerations have traditionally limited the role of radiation therapy in the context of primary and secondary cardiac malignancies. Stereotactic body radiotherapy (SBRT) is a promising modality for the delivery of focused high-dose radiation with ablative potential to complex targets such as small, deep-seated, moving lesions, allowing also for re-irradiation. Methods Between January 2013 and October 2013, 3 patients underwent SBRT for cardiac lesions: 2 patients had recurrent, previously irradiated cardiac angiosarcomas (PCA) and 1 patient had a cardiac metastasis from melanoma. They were treated with fiducial-guided robotic radiotherapy with CyberKnife. As for dose prescription, 24 Gy in 3 fractions (80% isodose) and 30 Gy in 5 fractions (80% isodose) were administered to the recurrent PCAs and cardiac metastasis, respectively. Results At 2 months after SBRT, cardiac MRI showed a partial response in the patients treated for recurrent PCA while the cardiac metastasis remained stable. In all cases, absence of local progression was subsequently confirmed by contrast-enhanced cardiac MRI after 6 months, without any evidence of treatment-related side effects. Conclusions Fiducial-guided SBRT proved to be feasible and effective in preventing local disease progression in selected patients with cardiac malignancies.
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Bonomo P, Livi L, Rampini A, Meattini I, Agresti B, Simontacchi G, Paiar F, Mangoni M, Bonucci I, Greto D, Masi L, Doro R, Marrazzo L, Biti G. Stereotactic body radiotherapy for cardiac and paracardiac metastases: University of Florence experience. Radiol Med 2013; 118:1055-65. [DOI: 10.1007/s11547-013-0932-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Accepted: 02/14/2012] [Indexed: 12/25/2022]
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Gardner EA, Sumanaweera TS, Blanck O, Iwamura AK, Steel JP, Dieterich S, Maguire P. In vivo dose measurement using TLDs and MOSFET dosimeters for cardiac radiosurgery. J Appl Clin Med Phys 2012; 13:3745. [PMID: 22584173 PMCID: PMC5716562 DOI: 10.1120/jacmp.v13i3.3745] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Revised: 11/15/2011] [Accepted: 01/31/2012] [Indexed: 11/24/2022] Open
Abstract
In vivo measurements were made of the dose delivered to animal models in an effort to develop a method for treating cardiac arrhythmia using radiation. This treatment would replace RF energy (currently used to create cardiac scar) with ionizing radiation. In the current study, the pulmonary vein ostia of animal models were irradiated with 6 MV X‐rays in order to produce a scar that would block aberrant signals characteristic of atrial fibrillation. The CyberKnife radiosurgery system was used to deliver planned treatments of 20–35 Gy in a single fraction to four animals. The Synchrony system was used to track respiratory motion of the heart, while the contractile motion of the heart was untracked. The dose was measured on the epicardial surface near the right pulmonary vein and on the esophagus using surgically implanted TLD dosimeters, or in the coronary sinus using a MOSFET dosimeter placed using a catheter. The doses measured on the epicardium with TLDs averaged 5% less than predicted for those locations, while doses measured in the coronary sinus with the MOSFET sensor nearest the target averaged 6% less than the predicted dose. The measurements on the esophagus averaged 25% less than predicted. These results provide an indication of the accuracy with which the treatment planning methods accounted for the motion of the target, with its respiratory and cardiac components. This is the first report on the accuracy of CyberKnife dose delivery to cardiac targets. PACS numbers: 87.53.Ly, 87.53.Bn
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Sharma A, Wong D, Weidlich G, Fogarty T, Jack A, Sumanaweera T, Maguire P. Noninvasive stereotactic radiosurgery (CyberHeart) for creation of ablation lesions in the atrium. Heart Rhythm 2010; 7:802-10. [DOI: 10.1016/j.hrthm.2010.02.010] [Citation(s) in RCA: 122] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2009] [Accepted: 02/05/2010] [Indexed: 11/29/2022]
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