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EP-1604 TRAINING OF LEFT-SIDED BREAST CANCER PATIENTS FOR RADIOTHERAPY USING DEEP INSPIRATION BREATH HOLD
ESTRO 31
S615
Conclusions: IGRT using 3 gold markers and MV EPI is feasible for our department and acceptable to patients. The impact on treatment machine workflow requires further study prior to offering this as a standard treatment option with our current linac capabilities. EP-1604 TRAINING OF LEFT-SIDED BREAST CANCER PATIENTS RADIOTHERAPY USING DEEP INSPIRATION BREATH HOLD L. Musted Nielsen1, M. Giørtz1 1 Vejle Hospital, Radiotherapy, Vejle, Denmark
FOR
Purpose/Objective: Deep inspiration breath hold (DIBH) for radiotherapy of left-sided breast cancer patients was first introduced at Vejle Hospital in late 2009 using ELEKTA's Active Breathing CoordinatorTM (ABC). The purpose of DIBH is to expand the chest cavity during radiotherapy, which increases the distance between the breast to be treated and the heart. This allows for a lower heart dose as well as better PTV coverage. Experience from an initial pilot project showed that thorough training coupled with appropriate screening of patients had a decisive influence on the success of the treatment. Therefore a small group of nurses were trained as DIBH instructors, responsible for the patient training and for screening patients for inability to complete a DIBH treatment. Here we present their experiences with patient training after 18 months of offering DIBH as the standard treatment for left sided breast cancer. Materials and Methods: The objective of patient training is to achieve a reproducible motion of the chest while under DIBH with the same volume inhaled. This is accomplished during a 30 minutes training session. First the objectives and process used during treatment are explained to the patient, and then the patient lies down on a mock-up of the treatment table. Once the patient is comfortably lying down and taking slow deep breaths on the table, some simple commands are introduced that are issued during treatment. After that the patient practices the deep breathing technique with guidance from the instructor until a reproducible expansion of the chest is obtained, and the patient’s inspiration volume for treatment is determined. The instructor continuously assesses the patient’s progress and ability to complete the full treatment course, while keeping in mind the exclusion criteria. Results: Vejle Hospital, Radiotherapy Department treats ca. 350 left sided breast cancer patients yearly. Of these ca. 30 patients are not treated using DIBH. The exclusion of these patients is mainly due to claustrophobia and problems with holding the ABC mouthpiece in place. Most of the patients complete the radiotherapy course without any complications from DIBH, however a small percentage undergo another training session, or have their inspiration volume reduced to allow the completion of the treatment course. Only a few patients have had to be excluded from DIBH treatment after starting treatment with DIBH, because the patients could not master radiation treatment while under DIBH. Conclusions: It is essential to give patients thorough training, where the focus is on patient education to master the techniques of DIBH. Those patients that fail to master DIBH, have a harder time during daily treatments, and may be unable to achieve the reproducibility of chest position between breath holds that is crucial for correct treatment. Also important is to have well defined exclusion criteria. EP-1605 IMPLEMENTING INTERVENTIONAL BRACHYTHERAPY IN A COMBINED 1.5 TESLA MRI/HDR TREATMENT ROOM; THE ROLE OF THE RTT R. Schokker1, K.M. van Vliet1, M.J.H. van Deursen1, J. Verkerk1, I.M. Jürgenliemk-Schulz1, A.A.C. de Leeuw1, M.A. Moerland1 1 U.M.C. Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands Purpose/Objective: Due to its superior soft-tissue contrast, magnetic resonance imaging (MRI) is valuable in image guided interventions like brachytherapy (BT). It provides better visualization of the target and critical structures at the moment of intervention. At the UMC Utrecht we built a dedicated treatment suite equipped with an HDR afterloader and a 1.5 T MR scanner, where patient treatment and MR imaging can be combined. Purpose of this combined interventional imaging and application approach is to treat patients with 3D MRI guided adaptive brachytherapy (IGABT) in a shorter timeframe and to control DVH parameters before start of irradiation. In this poster we describe the gain in time and the role of the RTT in the implementation process of this approach for gynaecological BT.
Materials and Methods: When MRI guided brachytherapy was started in our institute a few years ago, imaging was performed on the MR machines of the radiology department. Cooperation with MR technicians turned out to be very valuable; but for this new approach it was indispensable that the involved RTT had knowledge of MR physics and safety. Therefore, RTT's experienced in BT were educated in a professional MRI training institute and developed skills necessary for implementing the interventional IGABT approach. To enable cervical cancer BT applications inside the MRI room, RTT's were involved in the process of adapting the necessary tools (specula, obturators, iodination pliers etc.), other materials (like the MR trolley) and logistical procedures in order to develop a full MR compatible procedure. Results: In November 2011 a first patient with cervical cancer underwent a full MRI guided brachytherapy (BT) procedure (application, imaging and HDR treatment) in a 1.5 T MRI room in the UMC Utrecht. All instruments are MRI compatible, except the HDR afterloader and the ultrasound machine. Safe use of non MR compatible equipment is achieved by securing them to the wall . At this moment applications are performed on the adjusted MR trolley just outside the MR bore, approximately at the 5 Gauss line. Insertion of the applicator (MR compatible Utrecht Interstitial Fletcher Applicator) is safely possible at this distance. Ultrasound imaging used to control tandem insertion is also possible inside the MRI room. The ultrasound images are not disturbed by the magnetic field. Acquisition of MRI data sets is performed and monitored by RTT's. After treatment planning optimization and rescanning HDR BT is safely delivered inside the 1.5 T room. The radiation delivery by means of the conventional afterloader is not influenced by the MR scanner. RTT's are responsible for application security and safe logistics of the whole process. Working in this way has shortened the time between applicator insertion and irradiation for more than 1 hour. Conclusions: More than 1 hour time was gained in the whole process. Procedures are safe due to well trained and educated RTT staff. EP-1606 IMPLEMENTATION OF A NEW DIETARY AND LAXATIVE PROTOCOL IN PROSTATE CANCER PATIENTS TREATED BY RADIOTHERAPY J. Lozano1, O. Pera1, P. Foro1, J. Lio1, I. Membrive1, A. Reig1, N. Rodriguez1, X. Sanz1, J. Quera1, M. Algara1 1 Parc de Salut Mar. Hospital de l'Esperanca, Oncologia Radioteràpica, Barcelona, Spain Purpose/Objective: The position of the PTV in prostate cancer radiotherapy is affected by rectal distension. A distended rectum at the planning CT scan reduces disease control in this scenario (1, 2). The introduction of dietary and laxative protocols significantly decreases feces and rectal gas and reduces rectum distension at the CT planning scan (3). We have tried to implement foreign dietary protocols but they had not result in our environment. The objective of the study is to assess a new dietary and laxative protocol in our prostate cancer patients treated by external-beam radiotherapy in Barcelona. Materials and Methods: We designed a 'mediterranean adaptation' of the Dutch protocol published by Smitsmans et at. (3) . The protocol consists of an antiflatulent diet and the intake of 1g/5ml of magnesium hidroxide daily, starting 4 days before acquisition of the planning CT scan and 4 days before radiotherapy treatment up to the end of treatment. Patients were treated by three-dimensional conformal radiotherapy and intensity-modulated radiotherapy without image-guided radiotherapy techniques. CT planning scans of patients before the implementation of protocol were compared against the scans of patients subject to the new protocol. Rectal volume and rectal gas between the two groups were compared . Rectal distension was assessed calculating the average of the Cross-Sectional Area (CSA defined as the rectal volume divided by the length). According to De Crevosier et al. (1), we use a CSA higher to 11,2 cm2 as a threshold for an increased risk of biochemical and local failure. Results: Forty-nine no-protocol patients were compared against 46 patients subject to the new protocol. The rectal expansion were significantly lower among the protocol patients with an average CSA of 6.95 (+/- 0.54) cm2 vs. 9.30 (+/- 1.31) cm2; α=0.05, p=0.001. Only 2 patients (4.35%) had a CSA higher 11,2 cm2 in the protocol group compared to 10 patients (20.41%) in the no-protocol group. Conclusions: This protocol was well accepted by most of our patients and reduced significantly rectum distension at the CT planning scan. Further work will provide more data about improvements in disease control and toxicity and the usefulness in image-guided radiotherapy. (1)De Crevoisier et al, IJROBP, 62: 965-973, 2005
S615
Conclusions: IGRT using 3 gold markers and MV EPI is feasible for our department and acceptable to patients. The impact on treatment machine workflow requires further study prior to offering this as a standard treatment option with our current linac capabilities. EP-1604 TRAINING OF LEFT-SIDED BREAST CANCER PATIENTS RADIOTHERAPY USING DEEP INSPIRATION BREATH HOLD L. Musted Nielsen1, M. Giørtz1 1 Vejle Hospital, Radiotherapy, Vejle, Denmark
FOR
Purpose/Objective: Deep inspiration breath hold (DIBH) for radiotherapy of left-sided breast cancer patients was first introduced at Vejle Hospital in late 2009 using ELEKTA's Active Breathing CoordinatorTM (ABC). The purpose of DIBH is to expand the chest cavity during radiotherapy, which increases the distance between the breast to be treated and the heart. This allows for a lower heart dose as well as better PTV coverage. Experience from an initial pilot project showed that thorough training coupled with appropriate screening of patients had a decisive influence on the success of the treatment. Therefore a small group of nurses were trained as DIBH instructors, responsible for the patient training and for screening patients for inability to complete a DIBH treatment. Here we present their experiences with patient training after 18 months of offering DIBH as the standard treatment for left sided breast cancer. Materials and Methods: The objective of patient training is to achieve a reproducible motion of the chest while under DIBH with the same volume inhaled. This is accomplished during a 30 minutes training session. First the objectives and process used during treatment are explained to the patient, and then the patient lies down on a mock-up of the treatment table. Once the patient is comfortably lying down and taking slow deep breaths on the table, some simple commands are introduced that are issued during treatment. After that the patient practices the deep breathing technique with guidance from the instructor until a reproducible expansion of the chest is obtained, and the patient’s inspiration volume for treatment is determined. The instructor continuously assesses the patient’s progress and ability to complete the full treatment course, while keeping in mind the exclusion criteria. Results: Vejle Hospital, Radiotherapy Department treats ca. 350 left sided breast cancer patients yearly. Of these ca. 30 patients are not treated using DIBH. The exclusion of these patients is mainly due to claustrophobia and problems with holding the ABC mouthpiece in place. Most of the patients complete the radiotherapy course without any complications from DIBH, however a small percentage undergo another training session, or have their inspiration volume reduced to allow the completion of the treatment course. Only a few patients have had to be excluded from DIBH treatment after starting treatment with DIBH, because the patients could not master radiation treatment while under DIBH. Conclusions: It is essential to give patients thorough training, where the focus is on patient education to master the techniques of DIBH. Those patients that fail to master DIBH, have a harder time during daily treatments, and may be unable to achieve the reproducibility of chest position between breath holds that is crucial for correct treatment. Also important is to have well defined exclusion criteria. EP-1605 IMPLEMENTING INTERVENTIONAL BRACHYTHERAPY IN A COMBINED 1.5 TESLA MRI/HDR TREATMENT ROOM; THE ROLE OF THE RTT R. Schokker1, K.M. van Vliet1, M.J.H. van Deursen1, J. Verkerk1, I.M. Jürgenliemk-Schulz1, A.A.C. de Leeuw1, M.A. Moerland1 1 U.M.C. Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands Purpose/Objective: Due to its superior soft-tissue contrast, magnetic resonance imaging (MRI) is valuable in image guided interventions like brachytherapy (BT). It provides better visualization of the target and critical structures at the moment of intervention. At the UMC Utrecht we built a dedicated treatment suite equipped with an HDR afterloader and a 1.5 T MR scanner, where patient treatment and MR imaging can be combined. Purpose of this combined interventional imaging and application approach is to treat patients with 3D MRI guided adaptive brachytherapy (IGABT) in a shorter timeframe and to control DVH parameters before start of irradiation. In this poster we describe the gain in time and the role of the RTT in the implementation process of this approach for gynaecological BT.
Materials and Methods: When MRI guided brachytherapy was started in our institute a few years ago, imaging was performed on the MR machines of the radiology department. Cooperation with MR technicians turned out to be very valuable; but for this new approach it was indispensable that the involved RTT had knowledge of MR physics and safety. Therefore, RTT's experienced in BT were educated in a professional MRI training institute and developed skills necessary for implementing the interventional IGABT approach. To enable cervical cancer BT applications inside the MRI room, RTT's were involved in the process of adapting the necessary tools (specula, obturators, iodination pliers etc.), other materials (like the MR trolley) and logistical procedures in order to develop a full MR compatible procedure. Results: In November 2011 a first patient with cervical cancer underwent a full MRI guided brachytherapy (BT) procedure (application, imaging and HDR treatment) in a 1.5 T MRI room in the UMC Utrecht. All instruments are MRI compatible, except the HDR afterloader and the ultrasound machine. Safe use of non MR compatible equipment is achieved by securing them to the wall . At this moment applications are performed on the adjusted MR trolley just outside the MR bore, approximately at the 5 Gauss line. Insertion of the applicator (MR compatible Utrecht Interstitial Fletcher Applicator) is safely possible at this distance. Ultrasound imaging used to control tandem insertion is also possible inside the MRI room. The ultrasound images are not disturbed by the magnetic field. Acquisition of MRI data sets is performed and monitored by RTT's. After treatment planning optimization and rescanning HDR BT is safely delivered inside the 1.5 T room. The radiation delivery by means of the conventional afterloader is not influenced by the MR scanner. RTT's are responsible for application security and safe logistics of the whole process. Working in this way has shortened the time between applicator insertion and irradiation for more than 1 hour. Conclusions: More than 1 hour time was gained in the whole process. Procedures are safe due to well trained and educated RTT staff. EP-1606 IMPLEMENTATION OF A NEW DIETARY AND LAXATIVE PROTOCOL IN PROSTATE CANCER PATIENTS TREATED BY RADIOTHERAPY J. Lozano1, O. Pera1, P. Foro1, J. Lio1, I. Membrive1, A. Reig1, N. Rodriguez1, X. Sanz1, J. Quera1, M. Algara1 1 Parc de Salut Mar. Hospital de l'Esperanca, Oncologia Radioteràpica, Barcelona, Spain Purpose/Objective: The position of the PTV in prostate cancer radiotherapy is affected by rectal distension. A distended rectum at the planning CT scan reduces disease control in this scenario (1, 2). The introduction of dietary and laxative protocols significantly decreases feces and rectal gas and reduces rectum distension at the CT planning scan (3). We have tried to implement foreign dietary protocols but they had not result in our environment. The objective of the study is to assess a new dietary and laxative protocol in our prostate cancer patients treated by external-beam radiotherapy in Barcelona. Materials and Methods: We designed a 'mediterranean adaptation' of the Dutch protocol published by Smitsmans et at. (3) . The protocol consists of an antiflatulent diet and the intake of 1g/5ml of magnesium hidroxide daily, starting 4 days before acquisition of the planning CT scan and 4 days before radiotherapy treatment up to the end of treatment. Patients were treated by three-dimensional conformal radiotherapy and intensity-modulated radiotherapy without image-guided radiotherapy techniques. CT planning scans of patients before the implementation of protocol were compared against the scans of patients subject to the new protocol. Rectal volume and rectal gas between the two groups were compared . Rectal distension was assessed calculating the average of the Cross-Sectional Area (CSA defined as the rectal volume divided by the length). According to De Crevosier et al. (1), we use a CSA higher to 11,2 cm2 as a threshold for an increased risk of biochemical and local failure. Results: Forty-nine no-protocol patients were compared against 46 patients subject to the new protocol. The rectal expansion were significantly lower among the protocol patients with an average CSA of 6.95 (+/- 0.54) cm2 vs. 9.30 (+/- 1.31) cm2; α=0.05, p=0.001. Only 2 patients (4.35%) had a CSA higher 11,2 cm2 in the protocol group compared to 10 patients (20.41%) in the no-protocol group. Conclusions: This protocol was well accepted by most of our patients and reduced significantly rectum distension at the CT planning scan. Further work will provide more data about improvements in disease control and toxicity and the usefulness in image-guided radiotherapy. (1)De Crevoisier et al, IJROBP, 62: 965-973, 2005