Download deep inspiration breath hold technique

DEEP INSPIRATION BREATH
HOLD TECHNIQUE
A/PROF MARTIN BORG
ADELAIDE RADIOTHERAPY CENTRE
BC
BREAST CANCER
A MULTIDISCIPLINARY
APPROACH
SURGERY
RT
CT
TT
PATIENTS, CARERS,
DOCTORS, NURSES,
RT’S, PHYSICISTS,
DIETITIANS,
ACCOUNTANTS…
BC
 SA
Statistics

Most common cancer in women in SA (1,121 or 27.6%/yr)

Continual ↑ in last 10-15 yrs

3rd leading cause of cancer death in SA (234 or 14.7%/yr)

1989: screening mammography (50-69 yrs)

57% increase incidence of BC
82% increase in 50-69 year-olds

T<15 mm: 36% (2003) vs 13% (1989)
44% in 50-69 yr-olds

11% reduction in MR by 1997
20% in 50-69 yr-olds
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2011, SA Cancer Registry
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Cancer incidence + mortality rates (2011) + projections (2012-2014), SA
Females
Incidence (new cases)
Mortality (deaths)
Site/Yr
2011
2012
2013
2014
2011
2012
2013
2014
Breast
118.6
(1103)
58.1
(589)
31.4
(296)
30.4
(302)
22.1
(217)
426.7
(4123)
137.4
(1282)
60.7
(626)
35.2
(327)
31.7
(325)
19.5
(191)
431.9
(4221)
139.0
(1317)
60.8
(638)
35.1
(331)
31.9
(334)
19.7
(196)
432.3
(4291)
140.6
(1377)
61.0
(670)
35.1
(344)
32.1
(352)
19.8
(206)
432.7
(4477)
24.6
(244)
17.8
(190)
2.8
(28)
24.9
(256)
5.9
(63)
147.0
(1529)
30.1
(301)
23.6
(256)
3.2
(33)
24.0
(251)
7.9
(85)
161.2
(1698)
30.1
(306)
23.5
(259)
3.2
(34)
24.1
(257)
7.9
(87)
161.1
(1725)
30.1
(320)
23.4
(274)
3.2
(36)
24.1
(271)
8.0
(93)
160.9
(1815)
CRC
Mel
Lung
NHL
All CA
Introduction to RT
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RADIOTHERAPY

RT is a clinical speciality dealing with the use of
ionising radiation in the treatment of patients
with:
1.
Malignant neoplasms (e.g. breast cancer)
2.
Benign neoplasms (e.g. desmoid tumours)
3.
Benign conditions (e.g. DC, keloids, Graves ds)
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RADIOTHERAPY

Aim

To deliver a precisely measured dose of RT to a
defined T or TV with as minimal damage to
surrounding healthy tissue, resulting in
1.
Eradication of tumour
2.
A high quality of life
3.
Prolongation of survival at a reasonable cost
4.
Palliation or prevention of symptoms if not
curable
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
Production of Radiation Therapy (X-rays)

Produced by directing an electric current
(energetic electrons) onto a carbon target

Electrons interact with either
1.
orbital electrons, or nucleus of target atom
2.
release kinetic energy
3.
KE is converted into electromagnetic
energy in the form of X-rays
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PRODUCTION OF X-RAYS
 Absorbed Dose: Gray (Gy)
The energy imparted per unit mass by ionising radiation to matter at a specific
point
 Unit: joule/kg
1 J/kg = 1 Gy = 100 rad (old unit) = 100cGy
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PHOTON CHARACTERISTICS
Skin-sparing effect useful for
treating deep-seated tumours
Left Breast RT – 1st + 2nd Phase
R + L Breast RT: Phase 2 (boost)
L Breast RT – Composite DVH
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ELECTRON CHARACTERISTICS
Region of relatively uniform dose followed by a rapid drop-off
Useful for treating superficial tumours or regions (e.g. chest wall)
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L SCF + Chest Wall RT
CT SIMULATION
CT Scan
Image
Through
Tumour Bed
Multileaf Collimators
REMOVAL
OF
HOT/COLD
SPOTS
LA CONE BEAM CT
QOL = Cure
Side-effects
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
Side-effects

Aim to avoid or minimise
1.
2.
3.
4.
5.
Better patient selection
Improved RT techniques
Better patient care
(a) education
(b) nutrition
(c) general health
Informed consent
MDT
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
Side-effects

Acute or late

Local or systemic

Systemic
1.
Lethargy
2.
Psychoemotional
3.
Social
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
Side-effects

Acute
1.
Cutaneous (erythema, desquamation)
2.
Subcutaneous
3.
Oedema
(a)
Breast
(b)
Upper limb
4.
Pain
5.
Hair loss (axilla)
The Past
The Present
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
Cutaneous/Subcutaneous Reactions

Occurs in all patients

Entry and exit site

Factors
1.
Treatment
2.
Patient
3.
Tumour
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
Treatment Factors
RT
1. technique
2. boost
 Surgery

3.
extensive surgery
surgical complications
re-excision

Chemotherapy
1.
concomitant (uncommon)
radiosensitisers (adriamycin/taxol: 3-4/52)
1.
2.
2.
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
Patient Factors
1.
excessive skin folds (obesity: inhomogeneity)
large breast
smoking
pre-existing vascular disease
poor nutrition
diabetes mellitus
autoimmune disease
genetics
personal hygiene, support, etc
(hot or very cold weather)
2.
3.
4.
5.
6.
7.
8.
9.
10.
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
Tumour Factors
1.
stage of cancer (≥ stage II tumour > x 2 risk)
2.
skin invasion
3.
site (lower quadrants/boost area)
4.
recurrent disease (direct effect, retreatment)
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
Management

Reactions will heal

Prophylactic
1.
Patient education + informed consent
2.
Modern RT planning (3-D CRT, fractionation)
3.
Moisturising cream
4.
Loose nonbinding clothing (cotton)
5.
Avoid talcum powder + hot/cold packs
6.
Avoid irritants (perfumes, aftershave), shaving blades
7.
Avoid UV light
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
Side-effects
Late
1.
Pain (breast, chest wall)
2.
Fibrosis
3.
Telangectasia
4.
Pigmentation
5.
Oedema
(a) Breast
(b) Upper limb (AD): breast alone 0-4%
breast + SCF 12%
breast + axilla 33%

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
Side-effects

Late
6.
7.
6.
7.
8.
Pneumonitis and pulmonary fibrosis
Cardiac –
(a) IHD (1% @ 15 yrs)
(b) pericarditis
(c) not ventricular dysfunction(CT)
Brachial plexopathy (rare)
Osteoradionecrosis (rare)
Sarcoma, other second tumours (rare)
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

1.
2.
3.
4.
5.
6.
Reducing SE - Increasing TG
↓SE +↑T coverage +↓Geographical misses: go hand
in hand
Modern computerised CT planning (3-D CRT)
Sophisticated + precise dose-delivery systems
(software + hardware)
Daily online verification + virtual imaging (cone
beam CT: IGRT)
QA (planning, treatment)
Ongoing CME (education + innovation)
DIBH
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Cardiac
 1-3.5
↑
Toxicity (Left Breast RT)
% @ 10 years
RT doses > 50-66Gy
 DIBH
(single institutional studies)
1. ↓
Ht vol from 27-40 cc to 0-14 cc
2. ↓
Ht RT dose x 62%
3. ↓
Lung RT dose
DIBH
 1st
for South Australia
1.
> ½ million dollar investment in equipment @ ARC
2.
Trial comparing DIBH or voluntary breathing vs free
breathing (ARC, 2015)
3.
Protocol with robust QA
4.
In-house + overseas staff training
5.
Patient training
6.
Available to both public + private pts at ARC
7.
Ability to control LA with push button empowers pts
ABC EQUIPMENT
Pag
e 42
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 ARC
Study

2 comparable techniques were introduced

Left sided breast/chest wall +/- SCF/Axilla/IMC

1. Active breathing coordinator (ABC-using specialized Elekta
equipment)
2. Voluntary breath hold (VBH-without equipment; RMH, UK)

20 patients with left sided breast cancer: 2 CT simulation scans –
one in free breathing + the other in breath hold (ABC or VBH)

10 pts: ABC technique + 10 pts: VBH

Treatment plans were generated using standard RT technique

Dosimetric comparison between the 2 plans for the heart, left
lung + contralateral breast as per EviQ guidelines
ACTIVE BREATHING COORDINATOR

ABC

Assists pts hold their breath during treatment delivery

Device consists of
1.
mouthpiece
2.
nose clip
3.
breathing tube
4.
flow monitor
5.
valve to trigger a breath hold

Flow monitor + valve are connected to a computer displaying the breathing pattern, permitting the
operator to specify the breath hold volume (based on maximum comfortable lung volume + time

When a breath hold is triggered, the valve closes automatically (i.e once the pt reaches the breath
hold volume)

LA is turned on and pt irradiated only during the period when breathing is temporarily suspended

Pt is trained to breathe normally and breath hold with the ABC apparatus in the treatment position

Pt can switch of LA with the push of a button
1
Avoiding
1. Heart
2. Lung → 1. ↓ SE
3. GM
2. ↑ LC/OS
→ ↑ TG
ABC & VBH
Active Breathing cocoordinator
Voluntary Breath hold
Patient selection
Left Breast/Chestwall +/Supraclavicular,
Axilla/IMC fields
Left Breast/Chestwall
Only
Equipment
ABC unit-relies on
watching breathing
trace on monitor
No equipment- uses light
field and lasers in the
room matching marks
drawn on patient skin
Bolus
Yes
No
Additional Cost
Yes-mouthpiece-new
each day
No
Time
Breast/chestwall alone:
12 mins
+ SCF: 18 mins
25 mins
Consistency in setup
Yes
Mostly
Imaging
Day 1 & Weekly
Day 1-3 & Weekly
DIBH + 3-DCRT
HOT SPOTS + THE HEART
DIBH
HEART +
LUNG
DIBH
PUSHING THE HEART
AWAY
DIBH
PUSHING THE HEART AWAY
DIBH
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STUDY RESULTS (ARC, DIBH COMMITTEE)
RT Doses
Breath Hold (20-30 s)
Free Breathing
1.46 Gy
2.92 Gy
Heart V25
0.31 %
2.82 %
IL Lung Max Depth
2.6 cm
2.5 cm
IS Lung V20
13.5 %
16.0 %
Total Lung V20
6.2 %
7.3 %
9.2 Gy
21.0 Gy
0.8 %
2.1 %
Heart Mean
LAD mean
CL Breast V3
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ABC
(and VBH) resulted in significant ↓ in:
1.
mean heart RT dose
2.
heart V25
3.
LAD dose
4.
CL breast dose (V3)
5.
Total lung volumes
6.
Ipsilateral Lung V20
7.
Total Lung V20 lower
8.
Maximum heart depth in RT field
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 Patient
Feedback

“ It seems fairly straight forward as long as I remember not to take
too deep a breath”

“The very first session when I was orientated to the procedure,
tattoo’s etc. was very thorough, patient and respectful”

“I did find the snorkel mouth piece confronting but practiced
holding my breath whilst submerged in a deep bath with one of
my kid’s snorkels….the bath helped me relax and the incline of
the bath helped “sort of” simulate how I would be lying on the TX
couch”

“Breath Holding did make me feel anxious, it was nothing to do
with what the staff did or didn’t do it just is what it is; reassurance
was key from staff caring for me to help quell this each day”

Active Breath Control Radiation Therapy

What is active breath control (ABC) Radiation Therapy

Active breath control (ABC) is a technique whereby you hold your breath during your planning CT scan and treatment for up to 30 seconds at a
time.

Why should I have ABC?

The action of holding your breath inflates your lungs and pushes your heart away from your chest wall and away from the area being treated. This
is important to minimise any potential radiation damage to your heart. We only use ABC for patients having their left breast treated because the
heart sits behind the left breast and chest wall.

As everyone is different due to their size, shape and internal anatomy, we won’t know if you need to use ABC until you have had your first planning
CT scan. For some people, even when breathing normally, their heart will not be in the radiation field, so for them ABC is not necessary.

How can I prepare for ABC planning scan?

You do not need to do any specific preparation but you might like to practise holding your breath for 20 to 30 seconds at a time to get used to the
sensation.

What happens during my CT scan with ABC?

You will be asked to hold your breath through a plastic tube wearing a mouth piece and nose peg. The Radiation Therapist will explain and teach
you how to use the equipment.

Once you are happy with the process you will have a CT scan whilst holding your breath. The Radiation Therapist will speak to you and tell you
when to hold your breath and when to release it. You will be holding your breath for approximately 20 to 30 seconds at a time. If you are not able
to hold your breath or your chest does not move enough when you hold your breath, then ABC is not for you and we will give you your
radiotherapy whilst breathing normally.

What happens during my radiotherapy treatment with ABC?

Each time you have your radiotherapy treatment you will lie down on the treatment couch in the same position as you were for your CT scan. The
Radiation Therapist will move you into the correct position and will ask you to hold your breath and then release it several times until they are
happy with your position. The Radiation Therapists will then leave the treatment room and will speak to you through a microphone. When the
Radiation Therapists are ready to switch the radiation on they will ask you to hold your breath. You will hear the treatment machine switch on.
When the radiation beam is finished they will tell you to release your breath. This will happen several times until the treatment is finished. The
number of times that you need to hold your breath depends on how long you are able to hold it for.

A computer monitors your breathing and position, so if you release your breath without being told to, it will alert the Radiation Therapists and they
will switch the radiation off.

For further information view this video: https://youtu.be/4CDA4v-jXn0
Conclusions
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
Conclusions

Modern RT planning/delivery with DIBH
1.
Reduces geographical misses
2.
Reduces local side-effects
2.
Improves local control
3.
Improves overall survival
4.
Improves therapeutic gain
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Conclusions
 Radiation
therapy forms an essential
part of the MD management of BC
 Communication
between the medical
team and patient + family is essential
 Education
of the consumer + improved
access to information minimise the
adverse impact of BC on women and
their partners
REFERENCES
1.
Active
breathing
Coordinator
2015,
Respiratory
motion
management,
Elekta,
viewed
29
September
2015
<https://www.elekta.com/radiotherapy/treatmentsolutions/motion-management/active-breathing-coordinator.html>
2.
Bartlett, F, Colgan, R, Donovan, E, Carr, K, Landeg, S, Clements, N,
McNair, H, Locke, I, Evans, P, Haviland, J, Yarnold, J & Kriby, A, 2014,
‘Voluntary Breath-hold technique for reducing heart dose in left
breast radiotherapy’, The journal of Visualised Experiments, vol. 89.
3.
Borst, G, et al, 2010, ‘Clinical results of image-guided deep
inspiration breast irradiation’ Int. J. Radiat.Oncol. Biol. Phys. Vol. 78,
pp.1345-1351.
4.
Sixel, K, Aznar, M, Ung, Y, 2001, ‘Deep inspiration breath hold to
reduce irradiated heart volume in breast cancer patients’, Int. J.
Radiat. Oncol. Biol. Phys. Vol. 49, pp.199-204.
5.
Royal Marsden Breast Cancer Update, London, October 2014.
Thank You