Respiration Induced Heart Motion and Indications of Gated Delivery for Left-Sided Breast Irradiation
To investigate respiration-induced heart motion for left-sided breast irradiation using a four-dimensional computed tomography (4DCT) technique and to determine novel indications to assess heart motion and identify breast patients who may benefit from a gated treatment.
Images of 4DCT acquired during free breathing for 20 left-sided breast cancer patients, who underwent whole breast irradiation with or without regional nodal irradiation, were analyzed retrospectively. Dose distributions were reconstructed in the phases of 0%, 20%, and 50%. The intrafractional heart displacement was measured in three selected transverse CT slices using D(LAD) (the distance from left ascending aorta to a fixed line [connecting middle point of sternum and the body] drawn on each slice) and maximum heart depth (MHD, the distance of the forefront of the heart to the line). Linear regression analysis was used to correlate these indices with mean heart dose and heart dose volume at different breathing phases.
Respiration-induced heart displacement resulted in observable variations in dose delivered to the heart. During a normal free-breathing cycle, heart-induced motion D(LAD) and MHD changed up to 9 and 11 mm respectively, resulting in up to 38% and 39% increases of mean doses and V(25.2) for the heart. MHD and D(LAD) were positively correlated with mean heart dose and heart dose volume. Respiratory-adapted gated treatment may better spare heart and ipsilateral-lung compared with the conventional non-gated plan in a subset of patients with large D(LAD) or MHD variations.
Proposed indices offer novel assessment of heart displacement based on 4DCT images. MHD and D(LAD) can be used independently or jointly as selection criteria for respiratory gating procedure before treatment planning. Patients with great intrafractional MHD variations or tumor(s) close to the diaphragm may particularly benefit from the gated treatment.
Available from: Wei Wang
- "However, in recent years, with the development of sophisticated image-guided online and offline setup verification and correction techniques, such as the electric portal imaging device (EPID) and cone-beam CT (CBCT), the interfraction setup error has been significantly reduced during delivery of irradiation in breast cancer patients [4-7]. Although the intrafractional breathing motion is usually only a few millimeters [8-10], respiratory-induced movement during free breathing has recently become the focus of radiotherapy research [8,9,11,12]. A number of studies have shown that the dosimetric impact of respiratory motion was clinically insignificant during free breathing [8,9]. "
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The purpose of this study was to explore the correlation between the respiration-induced target motion and volume variation with the dosimetric variance on breast and organ at risk (OAR) during free breathing.
Methods and materials
After breast-conserving surgery, seventeen patients underwent respiration-synchronized 4DCT simulation scans during free breathing. Treatment planning was constructed using the end inspiration scan, then copied and applied to the other phases and the dose distribution was calculated separately to evaluate the dose-volume histograms (DVH) parameters for the planning target volume (PTV), ipsilateral lung and heart.
During free breathing, the treated breast motion vector was 2.09 ± 0.74 mm, and the volume variation was 3.05 ± 0.94%. There was no correlation between the breast volume and target/OAR dosimetric variation (|r| = 0.39 ~ 0.48). In the anteroposterior, superoinferior and vector directions, breast movement correlated well with the mean PTV dose, conformal index, and the lung volume receiving high dose (|r| = 0.651-0.975); in the superoinferior and vector directions, breast displacement only correlated with the heart volume receiving >5 Gy (V5) (r = −0.795, 0.687). The lung volume and the lung volume receiving high dose correlated reasonably well (r = 0.655 ~ 0.882), and a correlation only existed between heart volume and V5 (r = −0.701).
Target movement correlated well with the target/OAR dosimetric variation in certain directions, indicating that whole breast IMRT assisted by breathing control or respiratory-adapted gated treatment promotes the accuracy of dose delivery during radiotherapy. During free breathing, the effect of breast volume variation can be ignored in whole breast IMRT.
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ABSTRACT: To identify dose-heart-volume constraints that correlate with the risk of developing asymptomatic valvular defects (VD) in Hodgkin's lymphoma (HL) patients treated with three-dimensional radiotherapy (RT).
Fifty-six patients undergoing cytotoxic chemotherapy (CHT) and involved-field radiation treatment for HL were retrospectively analyzed. Electro-echocardiography was performed before CHT, after CHT, and after RT. For the entire heart, for right and left ventricle (RV, LV), right and left atrium (RA, LA) percentage of volume exceeding 5-30Gy in increment of 5Gy (V(x)), and dosimetric parameters were calculated using 1.6Gy fraction as reference. To evaluate clinical and dosimetric factors possibly associated with VD, univariate and multivariate logistic regression analyses were performed.
At a median follow up of 70.5 months, 32.1% of patients developed VD (regurgitation and/or stenosis): 25.0% developed mitral, 5.4% developed aortic, and 14.3% tricuspid VD. In particular the percentage of LA exceeding 25Gy (LA-V(25)) and the percentage of LV exceeding 30Gy (LV-V(30)) correlated with mitral and aortic VD with an odds ratio (OR) of 5.7 (LA-V(25)>63.0% vs. LA-V(25)≤63.0%) and OR of 4.4 (LV-V(30)>25% vs. LV-V(30)≤25%), respectively. RV-V(30) correlated with tricuspid VD (OR=7.2, RV-V(30)>65% vs. RV-V(30)≤65%).
LA-V(25), LV- and RV-V(30) prove to be predictors of asymptomatic alteration of valve functionality.
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ABSTRACT: To identify the clinicopathologic characteristics, treatments, and outcomes of a series of patients with primary cardiac angiosarcoma (AS).
This retrospective case series was set in a tertiary referral center with a multidisciplinary clinic. Consecutive patients with institutionally confirmed pathologic diagnosis of cardiac AS from January 1990 to May 2011 were reviewed. Main outcome measures included patient demographics, tumor characteristics, management strategies, disease response, and survival.
Data from 18 patients (78 % male) were reviewed. Sixteen patients (89 %) had AS originating in the right atrium. At diagnosis, eight patients (44 %) had localized/locally advanced disease and ten patients (56 %) had metastatic disease. Initial treatment strategies included resection (44 %), chemotherapy (39 %), and radiotherapy (11 %). Of the eight patients with localized/locally advanced AS, two underwent macroscopically complete resection with negative microscopic margins, one underwent macroscopically complete resection with positive microscopic margins, one underwent macroscopically incomplete resection, two received chemotherapy followed by surgery and intraoperative radiotherapy, one received chemotherapy alone, and one died before planned radiotherapy. Median follow-up was 12 months. Median overall survival (OS) was 13 months for the entire cohort; median OS was 19.5 months for those presenting with localized/locally advanced AS and 6 months for those with metastatic disease at presentation (p = 0.08). Patients who underwent primary tumor resection had improved median OS compared with patients whose tumors remained in situ (17 vs. 5 months, p = 0.01).
Cardiac AS is associated with poor prognosis. Resection of primary tumor should be attempted when feasible, as OS may be improved. Nevertheless, most patients die of disease progression.
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