Voluntary Breath-hold Technique Research Articles

Voluntary versus ABC breath-hold in the context of VMAT for breast and locoregional lymph node radiotherapy including the internal mammary chain

BackgroundDeep-inspiration breath-hold (DIBH) reduces radiation dose to the heart in patients undergoing locoregional breast radiotherapy. In the context of tangential irradiation of the breast/ chest wall, a voluntary breath hold (vDIBH) technique has been shown to be as reproducible as a machine-assisted breath hold technique using the active breathing co-ordinator (ABC™, Elekta, Crawley, UK, ABC_DIBH). This study compares set-up reproducibility for vDIBH versus ABC_DIBH in patients undergoing volumetric-modulated arc radiotherapy (VMAT) for breast cancer, both with and without wax bolus. MethodPatients with breast cancer requiring pan regional lymph node VMAT +/− wax bolus in breath-hold were CT scanned in vDIBH and ABC_DIBH. Patients were randomised to receive one technique for fractions 1–7 and the other for fractions 8–15. Daily cone beam computed tomography (CBCT) was performed and registered to planning-CT using bony anatomy. Within-patient comparisons of mean daily chest wall position were made using a paired t-test. Population, systematic (∑) and random errors (α) were estimated. Intrafraction reproducibility was assessed by comparing chest wall position and diaphragm movement between consecutive breath holds on CBCT. Results16 patients were recruited. All completed treatment with both techniques (9 patients with wax bolus, 7 patients without). CBCT derived ∑ were 2.1–6.4 mm (ABC_DIBH) and 2.1–4.9 mm (vDIBH), α were 1.7–2.6 mm (ABC_DIBH) and 2.2–2.7 mm (vDIBH) and mean daily chest wall displacements (MD) were 0.0–1.5 mm (ABC_DIBH) and -0.1–1.6 vDIBH (all p non-significant). Chest wall and diaphragm position was equivalent between consecutive breath holds in ABC and vDIBH (median difference 1.0 mm and 0.8 mm respectively, non p significant) demonstrating equivalent intrafraction reproducibility. ConclusionThis study demonstrates that a simple voluntary breath hold technique is feasible in combination with VMAT (+/− bolus) and is as reproducible as ABC_DIBH with VMAT for the irradiation of the breast and axillary and IMC lymph nodes in breast cancer patients.

Voluntary breath-hold reduces dose to organs at risk in radiotherapy of left-sided breast cancer.

To compare the dose to organs at risk with free breathing (FB) or voluntary breath-hold (VBH) during radiotherapy of patients with left sided breast cancer. Radiotherapy reduces the risk of breast-cancer-specific mortality but the effects on other organs increase non-cancer-specific mortality. Radiation exposure to the heart, in particular in patients with left sided breast cancer, can be reduced by breath hold methods that increase the distance between the heart and the radiation field. Three-dimensional conformal radiotherapy (3D-CRT) dose plans for the left breast and organs at risk including the heart, left anterior descending coronary artery (LAD) and ipsilateral lung were compared with FB and VBH in ten patients with left sided breast cancer. The mean doses to the heart and LAD were reduced by 50.4 % (p<0.001) and 58.8 % (p=0.006), respectively, in VBH relative to FB. The mean dose to the ipsilateral lung was reduced by 13.8 % (p=0.11) in VBH relative to FB. The planning target volume (PTV) coverage was at least 95 % in both FB and VBH (p=0.78). The VBH technique significantly reduces the dose to organs at risk in 3D-CRT treatment plans of left sided breast cancer.

127. Voluntary Breath Hold (VBH) technique versus free breath standard technique (FB), in radiotherapy treatment of left side breast cancer. First results in our center

PurposeRecent studies on patients undergoing radiotherapy of left side breast demonstrate that late heart damage is directly related to the average doses to the entire organ, apparently without threshold [1], and the maximum doses to its principal arteries [2].The VBH technique makes it possible to reduce the dose to the heart compared to FB [3]. Methods and materialsThis technique can be done in three different ways: (a) with active breathing control devices, based on spirometric systems; (b) with respiratory gating based on the visualization, by infrared camera, of the reflecting markers of a phantom placed on the chest of the patient; (c) with tattoo visual control based technique that identifies the patient’s position in deep inhale, both in simulation CT scan and in the treatment phase. While the first two techniques require investment in equipment and accessories, the third, adopted by our center, is achievable with what is normally available in a radiotherapy department.For the first 9 patients, treatment plans were implemented in both FB and VBH. ResultsThe results obtained, reported in Table 1, are encouraging. At equal coverage of target and dose to the lung, there is a noticeable decrease in dose to the heart and to the left anterior descending artery. ConclusionsThe adopted technique is a valid aid to the radiotherapy of breast cancer in selected patients.

Deep Inspiration Breath Hold Techniques in the Radiotherapeutic Management of Left-Sided Breast Cancer-Active Breathing Coordinator vs. Voluntary Breath Hold

Purpose: Deep Inspiration Breath Hold (DIBH) is a well-established method in reducing their radiation of the heart and lung when treating Left sided Breast cancer with EBRT. There is, however, limited literature comparing different methods of DIBH. The purpose of our study is to compare the efficacy of Active Breathing Co-ordinator (ABC) against Voluntary Breath Hold (VBH). Methods and Materials: 20 patients were selected whom had left sided Breast cancer and underwent EBRT. 10 patients underwent Active Breathing Coordinator (ABC) using specialized Elekta equipment and 10 performed Voluntary Breath Hold (VBH) following the JOVE protocol. All 20 patients had two CT simulation scans: one in FB and the other in DIBH. Treatment plans were generated using a tangential radiation therapy technique. A dosimetric comparison was made between the two plans as per EviQ guidelines. Measurements were collected for Lung V20 (%), Ipsilateral Lung Maximum Depth (cm), Heart V25 (%), Heart (Gy), and Contralateral Breast V3 (%). 9 patients had LAD mean values measured. Results: When using the Mann-Whitney U test to compare ABC to VBH: the VBH technique yielded a median Heart (Gy) of 1.75 (IQR=1.15) and median Contralateral Breast V3 of 0.31% (IQR=0.89%). The ABC technique yielded a median Heart (Gy) of 1.44 (IQR=.60) and for the Contralateral Breast V3 a median of 0.00% (IQR=0.00%). The ABC technique was statistically superior with U=15.000 p =.008 (Heart (Gy)) and U=24.500 p=.035 (Contralateral Breast V3) respectively. None of the other parameters had statistically significant median differences. When using the Wilcoxon signed-rank test to compare DIBH to FB: The VBH technique yielded a median Ipsilateral Lung max (cm) of 2.3, Ipsilateral Lung V20 of 13.92%, Lung V20 of 6.45%, Heart V25 of 2.41%, Heart (Gy) of 2.7, and LAD mean (Gy) of 23.4. The DIBH technique was statistically superior in these parameters and yielded a median Ipsilateral Lung max (cm) of 2.6 (Z=-3.072 p=.002), Ipsilateral Lung V20 of 12.33% (Z=-2.576 p=.01), Lung V20 of 5.84% (Z=-2.296 p=.01), Heart V25 of 0.26% (Z=- 3.921 p<.001), Heart (Gy) of 1.43 (Z=-3.921 p<.001), and LAD mean (Gy) of 7.7 (Z=-2.201 p=.028). Conclusion: ABC is a superior breath hold technique when compared to VBH and will yield lesser long-term cardiac complications. However, it is a more expensive modality and can be poorly tolerated by patients. Surrounding structures incur significantly less radiation when using DIBH than FB which is consistent with previous studies in the literature. Further studies are required to confirm this data.

The UK HeartSpare Study (Stage II): Multicentre Evaluation of a Voluntary Breath-hold Technique in Patients Receiving Breast Radiotherapy

AimsTo evaluate the feasibility and heart-sparing ability of the voluntary breath-hold (VBH) technique in a multicentre setting. Materials and methodsPatients were recruited from 10 UK centres. Following surgery for early left breast cancer, patients with any heart inside the 50% isodose from a standard free-breathing tangential field treatment plan underwent a second planning computed tomography (CT) scan using the VBH technique. A separate treatment plan was prepared on the VBH CT scan and used for treatment. The mean heart, left anterior descending coronary artery (LAD) and lung doses were calculated. Daily electronic portal imaging (EPI) was carried out and scanning/treatment times were recorded. The primary end point was the percentage of patients achieving a reduction in mean heart dose with VBH. Population systematic (Σ) and random errors (σ) were estimated. Within-patient comparisons between techniques used Wilcoxon signed-rank tests. ResultsIn total, 101 patients were recruited during 2014. Primary end point data were available for 93 patients, 88 (95%) of whom achieved a reduction in mean heart dose with VBH. Mean cardiac doses (Gy) for free-breathing and VBH techniques, respectively, were: heart 1.8 and 1.1, LAD 12.1 and 5.4, maximum LAD 35.4 and 24.1 (all P<0.001). Population EPI-based displacement data showed Σ =+1.3–1.9 mm and σ=1.4–1.8 mm. Median CT and treatment session times were 21 and 22 min, respectively. ConclusionsThe VBH technique is confirmed as effective in sparing heart tissue and is feasible in a multicentre setting.

Robustness of the Voluntary Breath-Hold Approach for the Treatment of Peripheral Lung Tumors Using Hypofractionated Pencil Beam Scanning Proton Therapy

The safe clinical implementation of pencil beam scanning (PBS) proton therapy for lung tumors is complicated by the delivery uncertainties caused by breathing motion. The purpose of this feasibility study was to investigate whether a voluntary breath-hold technique could limit the delivery uncertainties resulting from interfractional motion. Data from 15 patients with peripheral lung tumors previously treated with stereotactic radiation therapy were included in this study. The patients had 1 computed tomographic (CT) scan in voluntary breath-hold acquired before treatment and 3 scans during the treatment course. PBS proton treatment plans with 2 fields (2F) and 3 fields (3F), respectively, were calculated based on the planning CT scan and subsequently recalculated on the 3 repeated CT scans. Recalculated plans were considered robust if the V95% (volume receiving ≥95% of the prescribed dose) of the gross target volume (GTV) was within 5% of what was expected from the planning CT data throughout the simulated treatment. A total of 14/15 simulated treatments for both 2F and 3F met the robustness criteria. Reduced V95% was associated with baseline shifts (2F, P=.056; 3F, P=.008) and tumor size (2F, P=.025; 3F, P=.025). Smaller tumors with large baseline shifts were also at risk for reduced V95% (interaction term baseline/size: 2F, P=.005; 3F, P=.002). The breath-hold approach is a realistic clinical option for treating lung tumors with PBS proton therapy. Potential risk factors for reduced V95% are small targets in combination with large baseline shifts. On the basis of these results, the baseline shift of the tumor should be monitored (eg, through image guided therapy), and appropriate measures should be taken accordingly. The intrafractional motion needs to be investigated to confirm that the breath-hold approach is robust.

EP-1310: An audit to assess the efficiency of a voluntary breath hold technique for breast cancer patients

EP-1310: An audit to assess the efficiency of a voluntary breath hold technique for breast cancer patients

The UK HeartSpare Study (Stage IB): Randomised comparison of a voluntary breath-hold technique and prone radiotherapy after breast conserving surgery

PurposeTo compare mean heart and left anterior descending coronary artery (LAD) doses (NTDmean) and positional reproducibility in larger-breasted women receiving left breast radiotherapy using supine voluntary deep-inspiratory breath-hold (VBH) and free-breathing prone techniques. Materials and methodsFollowing surgery for early breast cancer, patients with estimated breast volumes >750cm3 underwent planning-CT scans in supine VBH and free-breathing prone positions. Radiotherapy treatment plans were prepared, and mean heart and LAD doses were calculated. Patients were randomised to receive one technique for fractions 1–7, before switching techniques for fractions 8–15 (40Gy/15 fractions total). Daily electronic portal imaging and alternate-day cone-beam CT (CBCT) imaging were performed. The primary endpoint was the difference in mean LAD NTDmean between techniques. Population systematic (Σ) and random errors (σ) were estimated. Within-patient comparisons between techniques used Wilcoxon signed-rank tests. Results34 patients were recruited, with complete dosimetric data available for 28. Mean heart and LAD NTDmean doses for VBH and prone treatments respectively were 0.4 and 0.7 (p<0.001) and 2.9 and 7.8 (p<0.001). Clip-based CBCT errors for VBH and prone respectively were ⩽3.0mm and ⩽6.5mm (Σ) and ⩽3.5mm and ⩽5.4mm (σ). ConclusionsIn larger-breasted women, supine VBH provided superior cardiac sparing and reproducibility than a free-breathing prone position.

Voluntary Breath-hold Technique for Reducing Heart Dose in Left Breast Radiotherapy

Breath-holding techniques reduce the amount of radiation received by cardiac structures during tangential-field left breast radiotherapy. With these techniques, patients hold their breath while radiotherapy is delivered, pushing the heart down and away from the radiotherapy field. Despite clear dosimetric benefits, these techniques are not yet in widespread use. One reason for this is that commercially available solutions require specialist equipment, necessitating not only significant capital investment, but often also incurring ongoing costs such as a need for daily disposable mouthpieces. The voluntary breath-hold technique described here does not require any additional specialist equipment. All breath-holding techniques require a surrogate to monitor breath-hold consistency and whether breath-hold is maintained. Voluntary breath-hold uses the distance moved by the anterior and lateral reference marks (tattoos) away from the treatment room lasers in breath-hold to monitor consistency at CT-planning and treatment setup. Light fields are then used to monitor breath-hold consistency prior to and during radiotherapy delivery.

Voluntary Breath-hold Technique for Reducing Heart Dose in Left Breast Radiotherapy

Breath-holding techniques reduce the amount of radiation received by cardiac structures during tangential-field left breast radiotherapy. With these techniques, patients hold their breath while radiotherapy is delivered, pushing the heart down and away from the radiotherapy field. Despite clear dosimetric benefits, these techniques are not yet in widespread use. One reason for this is that commercially available solutions require specialist equipment, necessitating not only significant capital investment, but often also incurring ongoing costs such as a need for daily disposable mouthpieces. The voluntary breath-hold technique described here does not require any additional specialist equipment. All breath-holding techniques require a surrogate to monitor breath-hold consistency and whether breath-hold is maintained. Voluntary breath-hold uses the distance moved by the anterior and lateral reference marks (tattoos) away from the treatment room lasers in breath-hold to monitor consistency at CT-planning and treatment setup. Light fields are then used to monitor breath-hold consistency prior to and during radiotherapy delivery.

Radiothérapie thoracique en conditions stéréotaxiques : difficultés rencontrées lors de la mise en route et solutions proposées

The aim of this paper is to describe the difficulties encountered when implementing stereotactic radiotherapy of non-small cell lung cancer (T1-T2, N0, M0) using a voluntary breath-hold technique. From 25/03/2010 to 22/02/2011, eight patients with a non-small cell lung cancer were selected for treatment. CT images were obtained with the patient maintaining breath-hold using a spirometer. Treatment was delivered when the patient maintains this level of breath-hold. Treatment was performed with a 4MV and 10MV photon beams from a linear accelerator Varian 2100CS, equipped with a 120 leaves collimator. 60Gy or 48Gy were delivered, in four sessions, to the 80% isodose. The planning target volume (PTV) was defined by adding a 5mm margin to the internal target volume (ITV), the ITV corresponding to the gross tumour volume (GTV) plus a 3mm margin. CTV is considered equal to GTV. The non-understanding of the gating technique, the great number of beams and the limited breath-hold times led to the failure of some treatments. It can be explained by some patients insufficient respiratory abilities and the low dose rate of one of the beams used for treatment, thus forcing some radiation fields to be delivered in two or three times. Implementing such a technique can be limited by the patients’ physical abilities and the materials used. Some solutions were found: a training phase more intense with a coaching of the breath-hold technique more precise, or the use of an abdominal compression device.

Reproducibility of The Abdominal and Chest Wall Position by Voluntary Breath-Hold Technique Using a Laser-Based Monitoring and Visual Feedback System

The voluntary breath-hold (BH) technique is a simple method to control the respiration-related motion of a tumor during irradiation. However, the abdominal and chest wall position may not be accurately reproduced using the BH technique. The purpose of this study was to examine whether visual feedback can reduce the fluctuation in wall motion during BH using a new respiratory monitoring device. We developed a laser-based BH monitoring and visual feedback system. For this study, five healthy volunteers were enrolled. The volunteers, practicing abdominal breathing, performed shallow end-expiration BH (SEBH), shallow end-inspiration BH (SIBH), and deep end-inspiration BH (DIBH) with or without visual feedback. The abdominal and chest wall positions were measured at 80-ms intervals during BHs. The fluctuation in the chest wall position was smaller than that of the abdominal wall position. The reproducibility of the wall position was improved by visual feedback. With a monitoring device, visual feedback reduced the mean deviation of the abdominal wall from 2.1 +/- 1.3 mm to 1.5 +/- 0.5 mm, 2.5 +/- 1.9 mm to 1.1 +/- 0.4 mm, and 6.6 +/- 2.4 mm to 2.6 +/- 1.4 mm in SEBH, SIBH, and DIBH, respectively. Volunteers can perform the BH maneuver in a highly reproducible fashion when informed about the position of the wall, although in the case of DIBH, the deviation in the wall position remained substantial.

Breathing adapted radiotherapy of breast cancer: reduction of cardiac and pulmonary doses using voluntary inspiration breath-hold

Background and purposeAdjuvant radiotherapy of breast cancer using wide tangential photon fields implies a risk of late cardiac and pulmonary toxicity. This CT-study evaluates the detailed potential dosimetric consequences of applying breathing adapted radiotherapy (BART), and the feasibility of a monitored voluntary breath-hold technique for right-sided as well as for left-sided tumours. Patients and methodsAfter breast-conserving surgery, 16 patients were CT-scanned in distinct respiratory phases using the varian real-time position management system™ for the monitoring of respiratory anterioposterior chest wall excursion. Each patient underwent three scans: during free breathing (FB), voluntary expiration breath-hold (EBH) and voluntary deep inspiration breath-hold (DIBH). For each scan, an optimised treatment plan was designed with conformal tangential fields encompassing the clinical target volume (CTV) of the breast and ipsilateral internal mammary nodes, and an anterior supraclavicular field. ResultsBreath-hold was well accepted by the patients, with a median duration of 24 s for both EBH and DIBH. The mean anterioposterior chest wall excursions were 2.5, 2.6 and 4.1 mm during FB, EBH and DIBH, respectively. During EBH, the mean front chest wall position was 2.7 mm posterior to its mid-FB position, and during DIBH 12.6 mm anterior to its mid-FB position. For right-sided tumours, the median ipsilateral relative lung volume receiving >50% of the prescribed CTV dose was 39, 49 and 32% for FB, EBH and DIBH, respectively. For left-sided tumours, the corresponding percentages were 37, 46 and 31%. The median heart volume receiving >50% of the prescription dose was reduced from 8% for FB to 1% for DIBH, and the median left anterior descending coronary artery volume was reduced from 54 to 5%. ConclusionsIrradiated cardiac volumes can consistently be reduced for left-sided breast cancers using DIBH for wide tangential treatment fields. Additionally, substantial dose reductions in the lung are observed for both right- and left-sided tumours.