Mary’s Story

In December 2008 Mary went from being a patient to a pioneer.

Suffering from a metastasis to the liver, the 70-year-old woman from rural Ohio became the first patient at the Precision Radiotherapy Center in West Chester, Ohio, to undergo radiotherapy with the help of new “respiratory gating” technology. The technology allows doctors to aim precise, high-dose beams of radiation at tumors that move with the breathing cycle without causing unnecessary damage to healthy tissue.

The procedure was painless for Mary, a retired housewife who underwent 12 treatments over a period of two and a half weeks. “I feel better now than when the treatments started,” she said, midway through the treatment process.

Mary was diagnosed with uterine cancer in July 2007. Doctors treated her with radiation and chemotherapy, while taking note of a small spot on her liver at that time. The chemotherapy kept the liver spot in check for a while, but it grew back with a vengeance in 2008.

Mary’s options were limited. She could undergo chemotherapy again, or she could undergo radiotherapy, an evolving, high-tech treatment in which potent, shaped beams of radiation are directed at the tumor. “My kids decided that radiotherapy was my best alternative,” Mary said.

“Radiotherapy was a good option for her, primarily because chemotherapy had kept the liver metastasis stable for a long time,” said Mary’s radiation oncologist, Dr. David Grisell. “If we could control the tumor in the liver, she had a chance for long-term disease control.”

Mary wasn’t a candidate for surgery, Dr. Grisell said, because of her age. It was also unclear that that the tumor could be safely removed.

Dr. Grisell, an associate professor of radiation oncology at the University of Cincinnati (UC), said that body radiosurgery was another, but not as desirable, option. “Conventional radiation is too difficult,” he said. “It’s too long and it doesn’t give you the biologic effect that you can get with a high dose of precision radiosurgery.”

Tumors in the lung and liver, unlike those in the brain or limbs, are not stationary. They move internally as patients breathe in and out. That movement previously forced specialists to treat larger areas around the tumor in order to compensate for the movement, harming healthy tissue in the process, and at times limiting the effectiveness of the radiation treatments.

The new “respiratory gating” technology, called ExacTrac X-Ray Adaptive Gating and manufactured by BrainLAB AG, enables radiation oncologists and physicists to synchronize treatment with the breathing cycle, directing radiation at a tumor in the liver or lung only during a specific time in the cycle – typically after the patient has exhaled – and interrupting the radiation when the tumor has moved out of the targeted area. During treatment, therefore, the radiation cycles on and off. The radiation is turned on when the lesion is within the “window of opportunity” and off when it’s outside.

A few weeks before her treatment began, markers (fiducials) were placed in Mary’s liver at Cincinnati’s University Hospital. The markers would enable the gating technology to determine when Mary’s liver was within the treatment window.

Mary had minimal side effects from the radiotherapy. “I was tired on the fourth day,” she recalled. “But it wasn’t bad; it was nothing like what I felt when I was first treated for uterine cancer. I was exhausted then.”

For Mary, the hardest part of the radiotherapy treatments was trying to breathe normally, so as to maximize the synchronization with the gating technology. “They told me to breathe normally, but the more you think about it, the more difficult it is to breathe normally,” she said. “But I’ve learned to breathe with the machine. When I hear the machine kick on, I keep my breathing out. I’m trying hard to cooperate.”

Dr. Grisell said he was pleased with the results. “The gating technology is a wonderful new tool in our armamentarium. It allows us to treat patients in a shorter period of time and potentially more effectively. And it allows us to treat patients who otherwise would have no other option, primarily because their tumors could not be safely removed.”

Mary, who lives “in a big old farmhouse in the country,” is looking forward to resuming the peaceful flow of her life. She enjoys doing housework and gardening, and she is entertaining the idea of getting some chickens. “I just want to get back out in my garden,” she said. “I’m able to sweep floors again, and I get my dishes done. I’ve learned that if I feel really tired, I just stop and rest until I get my strength back.”