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21.12.2014
Our award-winning blog brings you insights on health, nutrition and wellness from experts you can trust. The aim of radiation therapy treatment is to deliver an optimal dose of radiation to the tumor while minimizing the dose of radiation to the surrounding healthy tissue.
To account for motion within the body, Taussig Cancer Institute utilizes Elekta's Active Breathing Coordinator (ABC) - a non invasive devise that under the patient’s control pauses breathing during radiation treatment to halt internal motion - therefore allowing greater conformity of the radiation beam to the tumor.
The Active Breathing Coordinator increases the accuracy of the treatment by enabling reproducible tumor position within the body. Often, only four to six pauses are required for treatment delivery, and the system is designed with patient comfort and confidence in mind. Throughout treatment the patient remains in control of the Active Breathing Coordinator by depressing a handheld thumb switch.
A time display in the treatment room lets the patient know how much time remains to maintain his or her breath hold. During a starting phase, also called preparation phase, the patient is getting acquainted to the use of the spirometer. Thanks to the breath hold methods, the scanner images are not altered by respiratory movements ensuring higher quality and an optimized dosimetric planning. For each radiotherapy session, the patient realizes several breath holds lasting to about 20 seconds. 95% of patients are able to handle this method, whatever respiratory pathologies suffered by patients.
Challenges arise because tumors and critical structures (heart, lungs, and etc.) are constantly moving and adapting with normal physiological functions. The tumor is immobilized during the pause, which allows the clinician to maximize radiation delivery to the tumor, and avoid critical structures and healthy tissue. If the pressure is released from the thumb switch at any time, the treatment is stopped and the valve on the Active Breathing Coordinator is opened so the patient can breathe normally again.
These features allow patients to take an active part in his or her treatment, and help to reduce the risk of radiation to surrounding structures and healthy tissue. The clinical team is determining the optimum breath hold level in function of each patient respiratory capacity.


Gross tumor volumes were contoured on different CT images, and planning target volumes (PTVs) were obtained using different margins.
The patient is then invited to repeat by itself a breath hold at the same pulmonary volume level during imaging and radiotherapy sessions. For PTV-FB, intensity-modulated radiotherapy (IMRT) was designed with seven fields, and VMAT included two whole arcs. For PTV-DIBH, VMAT with three 135A° arcs was applied, and the corresponding plans were named: IMRT-FB, VMAT-FB, and VMAT-DIBH, respectively. Currently, complete surgical resection is the standard treatment for patients with EC who are medically fit [2].
However, chemo-radiotherapy has also achieved promising clinical outcomes for patients with advanced local EC, including squamous cell cancer and adenocarcinoma, as well as for those who are not fit for surgery [2a€“4]. Radiation therapy (RT) also continues to be a critical component for multimodality systemic treatment of EC [5, 6]. However, treatment-related pneumonitis is an acute and toxic side effect that can occur with RT for thoracic EC [7]. Advances have been made in RT technology that can be applied to EC, including the progression from two-dimensional RT to three-dimensional conformal radiotherapy (3D-CRT), intensity modulated radiotherapy (IMRT), intensity proton beam radiotherapy (IMPT), volumetric modulated radiotherapy (VMAT), and helical tomotherapy (HT) [5, 8a€“13]. In particular, IMRT, VMAT, and HT have achieved a more conformal and homogeneous dose distribution with the application of beam intensity modulated technology and a multileaf collimator (MLC) system compared with 3D-CRT.
VMAT also represents an extension of IMRT which facilitates synchronized variations in gantry speed, dose rate, and the shape of the MLC and jaws [14, 15].
Consequently, VMAT can achieve similar, if not better, dose distribution compared with IMRT with shorter treatment times and fewer monitor units (MUs) [15a€“19]. The application of VMAT to EC RT has obtained similar results, although a more extensive low dose region is involved which can affect normal tissue [9a€“13]. However, given the shorter duration of the treatment associated with VMAT and the other technologies available, the damage to normal tissue can be minimized [19].During RT for thoracic EC, displacement and deformation induced by breath motion are critical factors which affect treatment accuracy and precision.
In comparison, the displacement of the left-right (L-R) and anterior-posterior (AP) regions were smaller. However, application of active breathing control (ABC) has been observed to reduce the motion induced by respiration [21, 22].


In addition, lung volume can be effectively increased with DIBH, and this has the benefit of sparing lung tissue during RT. Cardiopulmonary function for each patient was carefully and objectively examined prior to enrollment in the study to ensure that the patients could coordinate ABC. All of the enrolled patients had good cardiopulmonary function with Karnofsky performance scores (KPS) ranging from 80a€“90. None of the patients had communication barriers with the administrators of this study, and the breath holding time in mDIBH with ABC for all patients reached 30A s.
This study was approved by the Research Ethics Board of the Shandong Cancer Hospital, and all patients agreed to the conditions of this trial. For mDIBH, CT scans were performed using the Elekta ABC system (Synergy 102a„?, Elekta, Crawley, UK), with the trigger threshold set at 80% of the peak value of DIBH. Furthermore, breath training was performed at least twice by each patient prior to scanning. The clinical target volume (CTV) included the GTV as well as an additional 3a€“5A cm in the cranio-caudal direction along the esophagus in order to include the possibility of microscopic spread. The PTV for FB plans (PTV-FB) included the addition of a 1.5A cm margin (for internal motion and setup error) which was applied in all three dimensions to the CTV [21]. Healthy lung tissue was also included in the total lung volume, while GTV was excluded.Radiotherapy plansBoth IMRT and VMAT plans were designed for PTV-FB, while VMAT was designed only for PTV-DIBH. These plans were administered using a VARIAN Trilogy linear accelerator (Varian Medical Systems, Palo Alto, CA, USA), and were named IMRT-FB, VMAT-FB, and VMAT-DIBH, respectively. The collimator angle was set to 45A° for the first and third arcs, and at 315A° for the second arc. Dose constraints for complications included minimizing doses for health lung (named total lung), heart, and spinal cord, while maintaining optimal target coverage and dose uniformity to the target volumes.



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