Group 5 – Jaclyn Wanie, Jacob Wudtke, Margaret Koehn Commented [NL1]: I think the part I am confused about
is whether you are comparing these two techniques or are
Working Title
A comparison of respiratory management using phase gating and end expiratory breath hold
(EEBH) to spare healthy liver tissue for SBRT liver patients.
Problem Statement
The problem is that sparing healthy liver tissue is difficult due to respiration that results in liver
movement during SBRT treatment.
Purpose Statement
The purpose of this comparison study is to measure liver motion during phase gating and EEBH
and measure dose sparing of the liver during SBRT treatments.
Hypothesis Statements
• H1A: The first research hypothesis (H1) is that phase gating will increase liver motion by
0.5 cm superiorly and inferiorly compared to EEBH
o You want to state this as what you want to prove. I just want to double check here
– this is what you think will happen, correct? Seems like this is opposite of H2
below where you are saying EEBH will spare more healthy liver.
• H10: The first Null hypothesis (H10) is that phase gating will not increase liver motion by
0.5 cm superiorly and inferiorly compared to EEBH
• H2A: The second research hypothesis (H2) is that utilizing EEBH will lead to 5% fewer
cubic centimeters of healthy liver volume receiving 15 Gy compared to phase gating
o Isn’t this the same as EEBH will deliver ≥ 5% liver sparing compared to phase
gating ??? (more scholarly language)
• H20: The second research hypothesis (H20) is that utilizing EEBH will not lead to 5%
fewer cubic centimeters of healthy liver volume receiving 15 Gy compared to phase
gating
Literature Review Summary
Stereotactic body radiation therapy (SBRT) is utilized in radiation oncology to treat small
lesions to a high dose with small margins.1 This results in a greater amount of spared healthy
tissue. Since SBRT delivers a large dose of radiation, up to around 74Gy,1 it is important for the
treatment to be reproducible. Without reproducibility, the high dose of radiation could be
deposited into healthy tissue instead of the lesion. Hepatocellular carcinoma (HCC) is a
malignancy that is commonly treated using SBRT. Since these lesions are in the liver and
therefore in the abdominal cavity, respiratory motion greatly affects the treatment. The liver
you doing both and thinking they'll both be better
compared to some other technique not mentioned here??
From your hypotheses - it looks like you are doing both and
expect both will be better but you have no measurable
metrics and no idea what you are comparing them to??
Commented [NL2]: so do we mean greater than/equal to
0.5 cm?
Commented [NL3]: @Jacob Wudtke OK - so using EEBH
will decrease healthy liver dose by < 5% compared to phase
gating??? Meaning you plan to decrease dose delivered to
the healthy liver by 5%?
Commented [JW4R3]: @Nishele Lenards Correct! We
use the first hypothesis to establish the overall liver volume
difference. It is mainly just a measurable that shows that
there is a difference between the two respiratory
techniques. For the actual volumetric data, we will be using
the liver constraint that specifies how many CC's of healthy
tissue are receiving 15 Gy or more per the RTOG Liver SBRT
Guidelines. So, hypothesis 2 is stating that the amount (in
CC) of healthy liver tissue encompassed within the 15Gy
isodose line with EEBH will be 5% less than with phase
gating. So instead of thinking of it as a decrease in healthy
liver dose, we are using the volumetric CC as our
quantitative value to compare the two. Would you like me
to add the 15 Gy portion to the second hypothesis? I did not
want to get super specific but I could add that for clarity
Commented [NL5R3]: @Jacob Wudtke you want it to be
as specific as the dose constraint is that you are measuring.
It has to be clear but not wordy.
Commented [JW6R3]: @Nishele Lenards I adjusted H2 to
reflect both the metric of cubic centimeters and 15 Gy.
moves with the patient’s respiration cycle since it is located near the diaphragm. Previously, the

attending physician would create a larger internal treatment volume (ITV)2 to account for the

lesion’s respiratory motion. However, treating a greater amount of tissue comes with more side

effects for the patient.2 Radiation Therapy Oncology Group (RTOG) 11123 studied the effects of

radiation therapy on the liver. This created the knowledge base of which organs are at risk

(OAR) of being damaged by SBRT to the liver, including the small bowel, large bowel, stomach,

esophagus, healthy liver, and more.3 When these OARs are damaged, the patient experiences

side effects such as liver cirrhosis and diarrhea.3 These side effects can be reduced by managing

respiratory motion during SBRT with reduced ITV volumes, amount of tissue treated, and

therefore side effects.

Respiratory management is a tactic used during radiation therapy that restricts internal

motion caused by breathing. Popularly, deep inspiration breath hold (DIBH) and end expiration

breath hold (EEBH) and utilized.2,4,5 Both DIBH and EEBH require the patient to hold their

breath, either at the top of their breath cycle or the bottom, respectively.4 Patients may have

trouble with this, because certain comorbidities such as Chronic Obstructive Pulmonary Disease

(COPD) can make it difficult to hold your breath for a long time. Otherwise, those who are

naturally short of breath may also have difficulty with the breath hold. Patients who have

difficulty holding their breath often struggle through these treatments, but respiratory

management is required to achieve optimal treatment outcomes. Not only is this uncomfortable

for patients, but inadequate breath holding can cause variances in treatment position from day to

day. Another option for respiratory management is to choose a respiratory phased gating window

for treatment.6 When this tactic is used, the patient will breathe naturally, but the treatment

system will only treat while the patient is in a specific window of their breathing cycle, most
commonly between 30% and 60% of their full inspiration.6 All of these methods allow patients to

receive the highest quality of radiation treatment with the least amount of side effects.

Many liver cancers are treated with radiation therapy, which produces great results.

However, the problem is that sparing healthy liver tissue is difficult due to respiratory motion. Commented [MK7]: Problem Statement

Respiratory motion management must be used, but patients continually struggle to properly

perform EEBH. Phased gating is much easier for the patient, but there is a large lapse in

literature comparing the effectiveness of EEBH and phased gating windows. The purpose of this

study is to determine whether the use of phase gating or EEBH is better for sparing healthy liver

tissue by limiting respiratory motion. Researchers tested that using EEBH and respiratory gating Commented [MK8]: Purpose Statement

will comparably reduce respiratory motion, and that using these methods of respiratory Commented [MK9]: H1/H2

management will reduce radiation dose to healthy liver tissue. Commented [MK10]: H3

References
1. Su, TS., Liu, QH., Zhu, XF. et al. Optimal stereotactic body radiotherapy dosage for
hepatocellular carcinoma: a multicenter study. Radiat Oncol 16, 79 (2021).
https://doi.org/10.1186/s13014-021-01778-6
2. Gargett M, Haddad C, Kneebone A, Booth JT, Hardcastle N. Clinical impact of removing
respiratory motion during liver SABR. Radiat Oncol. 2019;14(1):93. Published 2019 Jun 3.
doi:10.1186/s13014-019-1300-6.
3. Dawson LA, Winter KA, Knox JJ, Zhu A, Krishnan S, Guha C, Kachnic LA, Gillin MT,
Hong TS, Craig TD, Hosni A, Chen E, Noonan A, Koay EJ, Sinha R, Lock MI, Ohri N,
Dorth JA, Moughan J, Crane CH. NRG/RTOG 1112: randomized phase III study of
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carcinoma (HCC) (NCT01730937). ASTRO (American Society for Radiation Oncology).
10/23/2022. 52345
4. Oh SA, Yea JW, Kim SK, Park JW. Optimal Gating Window for Respiratory-Gated
Radiotherapy with Real-Time Position Management and Respiration Guiding System for
Liver Cancer Treatment. Sci Rep. 2019;9(1):4384. Published 2019 Mar 13.
doi:10.1038/s41598-019-40858-2
5. Motoharu Sasaki, Hitoshi Ikushima, Kanako Sakuragawa, Michihiro Yokoishi, Akira
Tsuzuki, Wataru Sugimoto, Determination of reproducibility of end-exhaled breath-holding
in stereotactic body radiation therapy, Journal of Radiation Research, Volume 61, Issue 6,
November 2020, Pages 977–984, https://doi.org/10.1093/jrr/rraa079
6. Zeng C, Li X, Lu W, et al. Accuracy and efficiency of respiratory gating comparable to deep
inspiration breath hold for pancreatic cancer treatment. J Appl Clin Med Phys.
2021;22(1):218-225. doi:10.1002/acm2.13137