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Innovative Respiratory Control System allows Radiotherapy more Precise Hitting

The technique can reduce the treatment volume by accurately targeting to the lesion sites without unnecessarily injury surrounding normal tissues.

Innovative Respiratory Control System allows Radiotherapy more Precise Hitting
"After chemotherapy, the residual tumors are deemed to recur someday. Passive therapeutic approach by looking for new regimen until tumor recurrence is not a good idea; instead, active approach by combined radiotherapy immediately following chemotherapy when the residual cells remains weak and less aggressive is highly recommended. Such approach can effectively reduce the incidence of the cancer regrowth or metastasis. As a result, the disease can be controlled earlier, leading to better survival” Dr. Kwan-Hwa Chi, one of the first six trainee of "oncology specialists” in Taiwan, by Prof. Paul Carbone, the internationally famous “the father of oncology medicine”, optimistically talked about his years of clinical experience. Dr. Chi is the director of Radiation Therapy & Oncology Division of Shin Kong Hospital, and he is also one of the few specialists owns board of radiotherapy and chemotherapy.
Mrs. Chang was a forty-eight year-old woman with stage IIIB lung cancer. After two courses of four-month per course chemotherapy treatment, the cancer decreased size to 70% and 40%, respectively. Two months later, the cancer not only regrew back at the primary site but also metastasized to cervical lymph nodes and brain. It became stage IV disease. Mrs. Chang pinned her hopes on Dr. Chi after a failure from “effective” but “short duration of response” chemotherapy. She received a full course of three-month combination of radiotherapy and chemotherapy to all disease sites. This time, the cancer was successfully long-term controlled and Mrs. Chang had returned her daily life. “Make sure getting rid of all tumors by integrated radiation sooner into chemotherapy programs to decrease the chance of tumor relapse and metastasis is my therapeutic strategy” said by Dr. Chi. He emphasized the importance of grashing the golden period with correct therapeutic approach. However, to control the toxiaties is the key of success.
Conventional anti-cancer treatment includes surgical removal of cancer, radiotherapy and chemotherapy. Several new therapies, including targeting therapy, immune therapy, thermal therapy, tumor microenvironment and metabolic modulation therapy, have gradually been developed and adopted. Well trained oncology specialists must know how to combined different therapeutic approaches to achieve the optimal treatment efficacy. Among all of these anti-cancer therapies, radiotherapy is frequently ignored by non-radiation oncologists. Actually, radiotherapy has evolved into stereotactic body radiation therapy (SBRT) under the assistance of modern medical imaging and computer science. SBRT is a non-invasive “bleedingless surgery” that targets the lesion sites by image navigation and multiple angle radiation beams  around the lesions. The advantage of SBRT includes minimal side effect, no necessity for hospitalization, and short treatment time. Clinical trials have demonstrated its efficacy in early stage lung cancer and liver cancer. Since the irradiation dose is high, the precision is therefore critical. If the tumor located at the site that may be moved by respiration, e.g. liver cancer or lung cancer near the diaphragm. A deviation more than 2 centimeters may occur from breathing. Therefore, the tumor margin may be underdosed if treatment volume is not large enough; or the normal tissue may be overtreated if the treatment volume is too large. Both can lead to treatment failure.
“It is impossible to perform radiosurgery without the good respiratory control technologies”. Dr. Chi has pointed out the major problem need a breakthrough. His department did not purchase expensive gating devices and breathing control equipment, because he felt they were not worthy. Alternatively, they adopted a paradigm shift concept that to design and integrate their treatment machines with their own technologies. Which include respiratory counteractive couch system, the respiration-motion-monitoring device Abches (that allow patients to self-control the respiration motion of their chest and abdomen), and oxygen breathing. These devices can effectively decrease  the target deviation caused by respiration movement. Several domestic and foreign medical institutions had shown their interest and requested a collaboration with his department.
- Respiratory Counteraction Couch System
The respiratory counteraction couch system was independently invented by Radiation Therapy & Oncology Division of Shin Kong Hospital. The system can detect the patient's respiration phase and initiate a counteractive movement to compensate the diaphragm shift caused by respiration movement. Such counteractive movement allows the tumor relatively retain on its “motionless” status during irradiation. The technique can reduce the treatment volume by accurately targeting to the lesion sites without unnecessarily injury surrounding normal tissues. Comparing to those expensive equipments and devices on the market, this respiratory counteraction couch system is time-saving, highly accessible to most patients who require such treatment.
- Respiration-motion-monitoring device for self-control of the respiration motion by the chest and abdomen (Abches)
This device, developed in cooperation with Japan manufacturer, is a respiration control system that allows patients to visually monitor their respiration motion from the motion of the chest and abdomen. The technology has been transferred to Taiwan GMP factory. The features of this device (Abches) include its simplicity and convenience, no need to plug in, no consumables, high stability and high sensitivity in detecting patient's respiration phase. Such as, the deep inspiration breath-hold technique during radiotherapy can enlarge the lung volume, increase the distance between the heart and the chest walls, and decrease the irradiation dose to the heart, leading to lower incidence of cardiovascular events several years after radiotherapy (especially for those patients with family history of cardiovascular disease).
- Breathing pure oxygen
Adoption of two above-mentioned devices, i.e. Respiratory Counteraction Couch System and Abches, with breathing pure oxygen can efficiently extend patient's breath-holding time for about 2 folds and therefore reduce Linac pausing time, while this method may also help patient keeping on shallow-breathing during tomotherapy. With the assistance of Abches, pure oxygen breathing and shallow breathing technique, Dr. Chi's teams can use tomotherapy for respiratory control therapy. Tomotherapy had no adequate respiration control method so far. With this technique, we could effectively reduce 50% shift of the lesion motion during the tomotherapy course.
Dr. Chi mentioned that, the best reward he learned from Prof. Carbone was to gain the confidence and abilities to solve problems. Therefore, in the field of anti-cancer research, Dr. Chi always explored, tested innovative therapeutics, which can be seen from his publications. He obtained several patents and innovative awards. In the future, he also planned to integrate the respiratory counteraction couch system with Abches into a multi-functional respiratory control couch system. This new couch system simultaneously contains three functions, the deep inspiration breath-hold technique, shallow breathing technique, and counteractive correction technique in one couch. With the aid of pure oxygen breathing, the respiration control system can be further upgraded. This new system can be used on all type of radiotherapy devices for different clinical scenarios. Even the old radiotherapy machine can immediately upgraded to respiratory control therapy without huge budgets. More cancer patients can therefore have high quality radiotherapy and minimal side effects.

(Editing by Nicole Yang, Research Center for Biotechnology and Medicine Policy)
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