Electromagnetic Transponder Based Tracking and Gating in the Radiotherapeutic Treatment of Thoracic Malignancies.

PURPOSE: This report details our institutional workflow and technique for use of the Calypso electromagnetic transponder system with respiratory gating for localization and tracking of lung tumors during stereotactic radiation therapy for early stage thoracic malignancies. METHODS AND MATERIALS: Sixteen patients underwent bronchoscopic fiducial placement of 3 transponders in small airways in proximity to the primary tumor. Transponders were placed <19 cm from the most anterior skin location of the patient for appropriate tracking functionality. Patients underwent simulation with 4-dimensional assessment and were treated with transponder based positional gating if tumors moved >5 mm in any direction. Tumor motion <5 mm was not gated and treated using an internal target volume approach. A 5 mm uniform planning target volume was used. Before treatment, fiducial placement and tumor location were verified by daily kilovoltage (kV) and cone beam computed tomography image guidance. Tracking limits were placed based on the movement of the transponders from the centroid of the structures on the maximum intensity projection image. The Calypso treatment system paused treatment automatically if beacons shifted beyond the predefined tracking limits. RESULTS: All 16 patients underwent successful implantation of the electromagnetic transponders. Eight patients exhibited tumor motion sufficient to require respiratory gating, and the other 8 patients were treated using a free breathing internal target volume technique. Difficulty with transponder sensing was experienced in 3 patients as a result of anatomic interference with the placement of the sensing arrays; each of these cases was successfully treated after making setup modifications. Triggered imaging of fiducials during treatment was consistent with real-time positioning determined by the Calypso tracking system. CONCLUSIONS: Respiratory gated electromagnetic based transponder guided stereotactic body radiation therapy using the workflow described is feasible and well tolerated in selected patients with early stage lung malignancies.

Minimally invasive chest wall resection: sparing the overlying, uninvolved extrathoracic musculature of the chest.

Patients with non-small cell lung cancer (NSCLC) that invades the chest wall are often thought not to benefit from minimally invasive surgery. Frequently, open techniques involve cutting noninvolved extrathoracic muscles that lie over the cancer to gain access to resect the ribs that contain malignancy. We reviewed a new technique involving 21 patients that eliminates cutting of the extrathoracic (trapezius, rhomboids, serratus anterior) muscles. Ribs with invading cancer are resected from inside of the chest instead of cutting the uninvolved muscles over them. The approach used can be a thoracotomy, robotic, or video-assisted technique.