Use of immobilisation bra for daily setup of patients with pendulous breasts undergoing radiotherapy.

PURPOSE: A feasibility study to evaluate the Chabner XRT® Radiation Bra (CIVCO Radiotherapy & Qfix, Coralville, IA, USA) as a customised immobilisation device for patients with pendulous breasts undergoing radiotherapy was conducted. METHODS: A total of 34 patients with large pendulous breasts were fitted with the Chabner XRT® Radiation Bra during RT. A mixed-method questionnaire was administered to both radiation therapists (RTTs) and patients. RTTs evaluated the effectiveness of the bra in setup. Patients appraised its comfort level and ease of wearing. Setup reproducibility was evaluated based on a departmental imaging protocol. Acute skin side effects were documented with photos and assessed using the Radiation Therapy Oncology Group (RTOG) classification. RESULTS: Of the patients, 27 (79.4%) completed the questionnaire. 23 patients felt comfortable wearing the bra while 20 felt less exposed during treatment. Reproducibility was acceptable, with a median (range) setup error (isocentre) of 0.0 cm (-0.6 to 0.7 cm; left/right), -0.1 cm (-0.5 to 1.2 cm; posterior) and 0.2 cm (-0.5 to 0.9 cm; inferior) achieved based on matched field borders on skin. However, repeated setups and imaging were required for 3 patients due to large breast size (cups D-G; size 4-5). Minimal skin toxicity (grade 0-1) was observed. No grade ≥ 2 was reported. 10 RTTs completed the survey. Male RTTs (n = 4) were not confident in assisting patients with bra fitting. 8 RTTs agreed that although it was difficult to reproduce the breast tissue for treatment, it helped patients to maintain the treatment position. CONCLUSION: Our study demonstrated the feasibility of using a customised bra which provided optimal setup reproducibility while maintaining minimal skin toxicity and patient comfort, especially the value-added modesty felt among Asian women during their breast cancer radiotherapy.

Skin marker combined with surface-guided auto-positioning for breast DIBH radiotherapy daily initial patient setup: An optimal schedule for both accuracy and efficiency.

BACKGROUND AND PURPOSE: By employing three surface-guided radiotherapy (SGRT)-assisted positioning methods, we conducted a prospective study of patients undergoing SGRT-based deep inspiration breath-hold (DIBH) radiotherapy using a Sentine/Catalys system. The aim of this study was to optimize the initial positioning workflow of SGRT-DIBH radiotherapy for breast cancer. MATERIALS AND METHODS: A total of 124 patients were divided into three groups to conduct a prospective comparative study of the setup accuracy and efficiency for the daily initial setup of SGRT-DIBH breast radiotherapy. Group A was subjected to skin marker plus SGRT verification, Group B underwent SGRT optical feedback plus auto-positioning, and Group C was subjected to skin marker plus SGRT auto-positioning. We evaluated setup accuracy and efficiency using cone-beam computed tomography (CBCT) verification data and the total setup time. RESULTS: In groups A, B, and C, the mean and standard deviation of the translational setup-error vectors were small, with the highest values of the three directions observed in group A (2.4 ± 1.6, 2.9 ± 1.8, and 2.8 ± 2.1 mm). The rotational vectors in group B (1.8 ± 0.7°, 2.1 ± 0.8°, and 1.8 ± 0.7°) were significantly larger than those in groups A and C, and the Group C setup required the shortest amount of time, at 1.5 ± 0.3 min, while that of Group B took the longest time, at 2.6 ± 0.9 min. CONCLUSION: SGRT one-key calibration was found to be more suitable when followed by skin marker/tattoo and in-room laser positioning, establishing it as an optimal daily initial set-up protocol for breast DIBH radiotherapy. This modality also proved to be suitable for free-breathing breast cancer radiotherapy, and its widespread clinical use is recommended.

Recommendations for using analytical anisotropic algorithm and AcurosXB for epidermal dose calculations in breast radiotherapy from an in vivo Gafchromic film study.

BACKGROUND AND PURPOSE: This study recommends clinical epidermal dose calculation methods based on in-vivo film measurements and registered skin dose distributions with the Eclipse (Varian Medical Systems) treatment planning system's Analytical Anisotropic Algorithm (AAA) and Acuros XB (AXB) dose calculation algorithms. MATERIALS AND METHODS: Eighteen AAA V13.6 breast plans were recalculated using AXB (dose to medium) V13.5 with the same beam parameters and monitor units as in the original plans. These are compared against in-vivo Gafchromic film measurements from the lateral and inferior breast regions. Three skin structures in the treatment planning system are evaluated: a surface layer of voxels of the body contour, a 0.2 cm internal skin rind, and a 0.5 cm internal skin rind. RESULTS: Systematic shifts are demonstrated between the film measurements of skin dose and the Eclipse dose calculations. On average, the dose to the surface layer of pixels is underestimated by AAA by 8% and overestimated by AXB by 3%. A 5 mm skin rind extended into the body can increase epidermal dose calculations on average by 8% for AAA and 4% for AXB. CONCLUSION: This is the first study to register in-vivo skin dose distributions in the breast to the treatment planning system for comparison. Based on the results from this study it is recommended that epidermal dose is calculated with a 0.5 cm skin rind for the AAA algorithm and with rind thickness up to 0.2 cm for the AXB algorithm.

Subclinical cardiac damage monitoring in breast cancer patients treated with an anthracycline-based chemotherapy receiving left-sided breast radiation therapy: subgroup analysis from a phase 3 trial.

OBJECTIVE: This study, derived from the phase 3 SAFE trial (ClinicalTrials.gov identifier: NCT2236806), explores subclinical cardiac damage in breast cancer patients receiving anthracycline-based chemotherapy and left-sided breast radiation therapy (RT). MATERIALS AND METHODS: Eligible patients were randomized to a cardioprotective pharmacological therapy (bisoprolol, ramipril, or both) or placebo, with cardiac surveillance at multiple time-point using standard and 3-dimensional echocardiography. Dosimetric parameters were analysed, including mean heart dose (MHD) and various metrics for heart substructures, employing advanced contouring techniques and auto-contouring software. RESULTS: In the analysis of left-sided breast RT patients, the study encompassed 39 out of 46 irradiated individuals, focusing on GLS and 3D-LVEF outcomes with ≥ 10% worsening, defined as subclinical heart damage. Distinct RT schedules were used, with placebo exhibiting the highest ≥ 10% worsening (36.4%). In terms of treatment arms, bisoprolol exhibited 11.1% worsening, while ramipril 16.7% and bisoprolol + ramipril 25%. For patients with no subclinical damage, the mean MHD was 1.5 Gy; for patients with subclinical heart damage, the mean MHD was 1.6 Gy (p = 0.94). Dosimetric parameters related to heart and heart substructures (left anterior descending artery, right and left atrium, right and left ventricle) showed no statistically significant differences between patients with and without subclinical damage. CONCLUSION: Our results emphasize the crucial role of cardioprotective measures in mitigating adverse effects, highlighting RT as having negligible influence on cardiac performance. An extended follow-up assessment of the whole series is warranted to determine whether a subclinical effect could significantly influence clinical outcomes and cardiac events.

Clinical outcomes of curative-intent multimodal management of chemorefractory nonmetastatic inflammatory breast cancer.

INTRODUCTION: Chemorefractory nonmetastatic inflammatory breast cancer (IBC) which progresses under neoadjuvant chemotherapy poses specific therapeutic challenges: either pursuing a curative-intent treatment with a salvage combination of radiotherapy and surgery or switching to second-line systemic treatments despite the absence of metastasis. Due to the rarity of this situation, no specific management guidelines exist and the outcomes of these patients remain uncertain. In this retrospective observational study, we aimed to report the clinical outcomes of patients treated in a curative intent for chemorefractory nonmetastatic IBC, with a multimodal salvage treatment combining radiotherapy and surgery. MATERIALS AND METHODS: This single-center retrospective observational study included all chemorefractory nonmetastatic IBC treated at the Institut Curie (Paris, France). Overall survival (OS), disease-free survival (DFS), and locoregional relapse-free survival (LRRFS) were calculated from the time of diagnosis and from the time of neoadjuvant chemotherapy interruption. RESULTS: Between January 2010 and January 2018, 7 patients presented with chemorefractory nonmetastatic IBC with a progressive disease during neoadjuvant chemotherapy. Overall, chemorefractory IBC patients were young (median age of 50 years), had a good performance status, and usually presented with node-positive tumors characterized by a combination of adverse histological factors such as triple-negative breast cancer (TNBC), grade III, and high proliferation index. From the date of pathological diagnosis, 1­year OS, DFS, and LRRFS were 64.3%, 53.6%, and 71.4%, respectively. From the date of neoadjuvant chemotherapy interruption, 1­year OS, DFS, and LRRFS were 47.6%, 19.0%, and 45.7%, respectively, and median OS, DFS, and LRRFS were 8.3, 5.0, and 5.0 months, respectively. CONCLUSION: The prognosis of chemorefractory nonmetastatic IBC treated with a multimodal approach combining surgery and radiotherapy is particularly reserved, despite the curative intent of the salvage treatment and the lack of distant metastasis at the time of treatment. Optimal treatment modalities are still to be defined in this rare but critical presentation of IBC.

Detection of setup errors with a body-surface laser-scanning system for whole-breast irradiation after breast-conserving surgery.

PURPOSE: We compared the setup errors determined by an optical imaging system (OSIS) in women who received breast-conserving surgery (BCS) followed by whole-breast radiotherapy (WBRT) with those from cone-beam computed tomography (CBCT) carried out routinely. METHODS: We compared 130 setup errors in 10 patients undergoing WBRT following BCS by analyzing the translational and rotational couch shifts via CBCT and OSIS. Patients were treated with intensity-modulated radiotherapy (IMRT). The patient outline extracted from the planning reference Computed tomography (CT) was used as the reference for OSIS and CBCT alignment during treatment. We detected the setup uncertainty using CBCT and OSIS at the first five fractionations of RT and then twice a week. RESULTS: The absolute translational setup error (mean ± Standard deviation (SD)) in x (lateral), y (longitudinal), and z (vertical) axes detected by the OSIS was 0.14 ± 0.18, 0.15 ± 0.14, and 0.13 ± 0.13 cm, respectively. The rotational setup error (mean ± SD) in Rx (pitch), Ry (roll), and Rz (yaw) axes was 0.77 ± 0.54, 0.76 ± 0.61, and 1.23 ± 0.95, respectively. Significant difference is observed only in one direction (Rx, p = 0.03) in the paired setup errors obtaining from OSIS and CBCT, without significant differences in five directions. CONCLUSION: OSIS is a repeatable and reliable system that can be used to detect misalignments with accuracy, which is capable of supplementing CBCT for WBRT after BCS. We believe that an OSIS may be easier to use, quicker, and reduce overall dose as this method of patient alignment does not require ionizing radiation.

A uniform and versatile surface-guided radiotherapy procedure and workflow for high-quality breast deep-inspiration breath-hold treatment in a multi-center institution.

PURPOSE: We share our experiences on uniformly implementing an effective and efficient SGRT procedure with a new clinical workflow for treating breast patients in deep-inspiration breath-hold (DIBH) among 9 clinical centers using 26 optical surface imaging (OSI) systems. METHODS: Our procedures have five major components: (1) acquiring both free-breathing (FB) and DIBH computed tomography (CT) at simulation to quantify the rise of the anterior surface, (2) defining uniformly a large region of interest (ROI) to accommodate large variations in patient anatomy and treatment techniques, (3) performing two-step setup in FB by first aligning the arm and chin to minimize breast deformation and reproduce local lymphnode positions and then aligning the ROI, (4) aligning the vertical shift precisely from FB to DIBH, and (5) capturing a new on-site reference image at DIBH to separate residual setup errors from the DIBH motion monitoring uncertainties. Moreover, a new clinical workflow was developed for patient data preparation using 4 OSI offline workstations without interruption of SGRT treatment at 22 OSI online workstations. This procedure/workflow is suitable for all photon planning techniques, including 2-field, 3-field, 4-field, partial breast irradiation (PBI), and volumetric-modulated arc therapy (VMAT) with or without bolus. RESULTS: Since 2019, we have developed and applied the uniform breast SGRT DIBH procedure with optimized clinical workflow and ensured treatment accuracy among the nine clinics within our institution. About 150 breast DIBH patients are treated daily and two major upgrades are achieved smoothly throughout our institution, owing to the uniform and versatile procedure, adequate staff training, and efficient workflow with effective clinical supports and backup strategies. CONCLUSION: The uniform and versatile breast SGRT DIBH procedure and workflow have been developed to ensure smooth and optimal clinical operations, simplify clinical staff training and clinical troubleshooting, and allow high-quality SGRT delivery in a busy multi-center institution.

A system for real-time monitoring of breath-hold via assessment of internal anatomy in tangential breast radiotherapy.

The deep inspiration breath-hold (DIBH) technique assists in sparing the heart, lungs, and liver during breast radiotherapy (RT). The quality of DIBH is currently assessed via surrogates which correlate to varying degrees with the patient's internal anatomy. Since modern linacs are equipped with an electronic portal imaging device (EPID), images of the irradiated anatomy streamed from EPIDs and analyzed in real time could significantly improve assessment of the quality of DIBH. A system has been developed to quantify the quality of DIBH during tangential breast RT by analyzing the "beam's eye view" images of the treatment fields. The system measures the lung depth (LD) and the distance from the breast surface to the posterior tangential radiation field edge (skin distance, SD) at three user-defined locations. LD and SD measured in real time in EPID images of two RT phantoms showing different geometrical characteristics of their chest wall regions (computed tomography dose index [CTDI] and "END-TO-END" stereotactic body radiation therapy [E2E SBRT]) were compared with ground truth displacements provided by a precision motion platform. Performance of the new system was evaluated via static and dynamic (sine wave motion) measurements of LD and SD, covering clinical situations with stable and unstable breath-hold. The accuracy and precision of the system were calculated as the mean and standard deviation of the differences between the ground truth and measured values. The accuracy of the static measurements of LD and SD for the CTDI phantom was 0.31 (1.09) mm [mean (standard deviation)] and -0.10 (0.14) mm, respectively. The accuracy of the static measurements for E2E SBRT phantom was 0.01 (0.18) mm and 0.05 (0.08) mm. The accuracy of the dynamic LD and SD measurements for the CTDI phantom was -0.50 (1.18) mm and 0.01 (0.12) mm, respectively. The accuracy of the dynamic measurements for E2E SBRT phantom was -0.03 (0.19) mm and 0.01 (0.11) mm.

Comparison between the use of hypofractionated and conventionally fractionated radiotherapy in early breast cancer: A single-center real-world study in Taiwan.

BACKGROUND/PURPOSE: This study aimed to analyze the long-term outcomes of hypofractionated whole-breast irradiation (WBI) (HF-WBI) compared with those of conventionally fractionated WBI (CF-WBI) for early breast cancer treated with breast-conservation surgery (BCS) and adjuvant WBI in Taiwan. METHODS: This study included patients treated at our institution between 2012 and 2016. All patients with early breast cancer received BCS (pT1-2, pN0, M0) and adjuvant WBI through one of two treatment schemes. Propensity score matching analysis was conducted to create comparable cohorts. The major result is ipsilateral breast tumor recurrence (IBTR) rates and overall survival rates. RESULTS: A total of 869 patients with early-stage breast cancer received adjuvant HF-WBI or CF-WBI were included. After matching, 718 patients were separated into two groups of the same number. With a median follow-up of 66 months, seven cases of IBTR were noted (three for CF, four for HF). There were no significant differences between the HF-WBI and CF-WBI groups in 5-year IBTR rates (0.9% vs 0.6%, P = 0.3887, 95% CI [0.25-7.79]) and 5-year overall survival rates (98.1% vs 98.9%, P = 0.4702, 95% CI [0.32-3.49]). In our institution, the use of HF-WBI increased significantly from 5% before 2012 (Q3) to 92% in 2016 (Q4). There was no significant difference in grade 1-2 toxicity between the two treatment groups. Fewer cases of grade 3 skin toxicity noted in the HF-WBI group (zero vs four events). CONCLUSION: HF-WBI had similar IBTR, OS and toxicity to CF-WBI.

Combination of Olaparib with radiotherapy for triple-negative breast cancers: One-year toxicity report of the RADIOPARP Phase I trial.

Triple-negative breast cancer (TNBC) cells are sensitive to PARP1 inhibitors in vitro. The combination of Olaparib and radiotherapy for TNBC is currently evaluated in the Phase I RADIOPARP trial. RADIOPARP is a monocentric prospective open-label Phase I dose-escalation trial evaluating the combination of breast radiotherapy and Olaparib in TNBC patients with inflammatory, locoregionally advanced or metastatic disease, or with residual disease after neoadjuvant chemotherapy. Olaparib was orally given at increasing dose levels (50, 100, 150 or 200 mg twice a day [BID]); radiotherapy consisted of 50 Gy to the breast or chest wall with or without lymph node irradiation. Twenty-four TNBC patients were enrolled between September 2017 and November 2019. Olaparib was escalated to 200 mg BID without dose-limiting toxicities. At 1-year follow-up, no treatment-related grade ≥3 toxicity was observed. One patient (4.2%) had persistent grade 2 adverse events (breast pain, fibrosis and deformity). There was no cardiac, pulmonary or digestive toxicity related to treatment. The 1-year follow-up report of the RADIOPARP Phase I trial, evaluating Olaparib associated with breast radiotherapy in TNBC patients, consequently demonstrated an excellent toxicity profile of this combination with few low-grade adverse events.

Assessing the performance of an automated breast treatment planning software.

PURPOSE: To assess the dosimetric performance of an automated breast planning software. METHODS: We retrospectively reviewed 15 breast cancer patients treated with tangent fields according to the RTOG 1005 protocol and 30 patients treated off-protocol. Planning with electronic compensators (eComps) via manual, iterative fluence editing was compared to an automated planning program called EZFluence (EZF) (Radformation, Inc.). We compared the minimum dose received by 95% of the volume (D95%), D90%, the volume receiving at least 105% of prescription (V105%), V95%, the conformity index of the V95% and PTV volumes (CI95%), and total monitor units (MUs). The PTV_Eval structure generated by EZF was compared to the RTOG 1005 breast PTV_Eval structure. RESULTS: The average D95% was significantly greater for the EZF plans, 95.0%, vs. the original plans 93.2% (P = 0.022). CI95% was less for the EZF plans, 1.18, than the original plans, 1.48 (P = 0.09). D90% was only slightly greater for EZF, averaging at 98.3% for EZF plans and 97.3% for the original plans (P = 0.0483). V105% (cc) was, on average, 27.8cc less in the EZF breast plans, which was significantly less than for those manually planned. The average number of MUs for the EZF plans, 453, was significantly less than original protocol plans, 500 (P = 8 × 10-6 ). The average difference between the protocol PTV volume and the EZF PTV volume was 196 cc, with all but two cases having a larger EZF PTV volume (P = 0.020). CONCLUSION: EZF improved dose homogeneity, coverage, and MU efficiency vs. manually produced eComp plans. The EZF-generated PTV eval is based on the volume encompassed by the tangents, and is not appropriate for dosimetric comparison to constraints for RTOG 1005 PTV eval. EZF produced dosimetrically similar or superior plans to manual, iteratively derived plans and may also offer time and efficiency benefits.

Dosimetric evaluation of irregular surface compensator and intensity-modulated radiotherapy in breast radiotherapy.

BACKGROUND: This dosimetric study aims to evaluate the dosimetric advantage of the irregular surface compensator (ISC) compared with the intensity-modulated radiotherapy (IMRT). MATERIALS AND METHODS: Ten patients with whole breast irradiation were planned with the ISC and IMRT techniques. Six different beam directions were selected for IMRT and ISC plans. The treatment plans were evaluated with respect to planning target coverage, dose homogeneity index (DHI) and organs at risk (OARs) sparing. Monitor units (MUs) and the delivery time were analysed for treatment efficiency. RESULTS: The ISC technique provides a better coverage of the PTV and statistically significantly better homogeneity of the dose distribution. For the ipsilateral lung and heart, ISC and IMRT techniques deliver almost the same dose in all plans. However, MU counts and delivery time were significantly lower with the IMRT technique (p < 0.05). CONCLUSION: For breast radiotherapy, when the ISC method was compared to the IMRT method, ISC provided better dose distribution for the target.

Analysis of breast cosmetic effects 3 years after breast-conserving surgery and intraoperative radiotherapy with and without adjuvant whole breast irradiation.

INTRODUCTION: Intraoperative radiotherapy (IORT) based on low-kV photons may be an option for early breast cancer patients. Following Targit trial results some of those patients should undergo whole breast irradiation (WBRT) additionally. MATERIAL AND METHODS: Since April 2010, IORT has been applied to early breast cancer patients. One hundred and fifty patients were prospectively followed up and examined to evaluate the side effects (pain, fibrosis, breast edema, telangiectasias). We present the results 3 years post-treatment. WBRT was given to 82 (54.7%) patients. RESULTS: Tumor cavity fibrosis grade II and more was observed in 18 (12%) patients, as grade III only in 2 (1.33%) patients. Breast tissue fibrosis outside tumor cavity grade II was observed only in 2 (1.33%) patients. Breast edema was present in 10 (6.66%) patients. WBRT administration led to increased frequency of higher grade tumor cavity fibrosis (P < .0001), breast fibrosis (P < .0001), breast edema (P = .003), and occurrence of telangiectasias (P = .03), with no influence on pain reported by patients. In case of WBRT, tumor location (P = .026) and size of the irradiated breast (P = .015) were independent risk factors for higher degree of breast fibrosis, as seroma evacuation 6 months post-WBRT (P = .036) was the only independent risk factor for higher level of tumor cavity fibrosis in multiple regression. CONCLUSIONS: The cosmetic result after IORT is good and comparable to other accelerated partial breast irradiation techniques. Administration of WBRT post-IORT in breast cancer patients increases the level of fibrotic changes, breast edema and telangiectasias 3 years post-treatment, but with no influence on pain.

Radiotherapy in Pregnancy-Associated Breast Cancer.

Breast radiotherapy during pregnancy is a matter of debate as both the efficacy of treatment and the safety of the developing fetus should be considered. Currently there is not enough data to support the safety of in-utero exposure to radiation even with modern radiotherapy techniques. So it is highly recommended that breast radiotherapy is postponed to after delivery, though it might be considered in very selected patients according to risk-benefit assessment.

A study of the dosimetric impact of daily setup variations measured with cone-beam CT on three-dimensional conformal radiotherapy for early-stage breast cancer delivered in the prone position.

PURPOSE: To evaluate the dosimetric impact of daily positioning variations measured with cone-beam computed tomography (CBCT) on whole-breast radiotherapy patients treated in the prone position. METHODS: Daily CBCT was prospectively acquired for 30 consecutive patients positioned prone. Treatment for early-stage (≤II) breast cancer was prescribed with standard dose (50 Gy/25 fractions) or hypofractionation (42.56 Gy/16 fractions) for 13 and 17 patients, respectively. Systematic and random errors were calculated from the translational CBCT shifts and used to determine population-based setup margins. Mean translations (±one standard deviation) for each patient were used to simulate the dosimetric impact on targets (PTV_eval and lumpectomy cavity), heart, and lung. Paired Student's t tests at α = 0.01 were used to compare dose metrics after correction for multiple testing (P < 0.002). Significant correlation coefficients were used to identify associations (P < 0.01). RESULTS: Of 597 total fractions, 20 ± 13% required patient rotation. Mean translations were 0.29 ± 0.27 cm, 0.41 ± 0.34 cm, and 0.48 ± 0.33 cm in the anterior-posterior, superior-inferior, and lateral directions leading to calculated setup margins of 0.63, 0.88, and 1.10 cm, respectively. Average three-dimensional (3D) shifts correlated with the maximum distance of breast tissue from the sternum (r = 0.62) but not with body-mass index. Simulated shifts showed significant, but minor, changes in dose metrics for PTV_eval, lung, and heart. For left-sided treatments (n = 18), mean heart dose increased from 109 ± 75 cGy to 148 ± 115 cGy. Shifts from the original plan caused PTV_eval hotspots (V105%) to increase by 5.2% ± 3.8%, which correlated with the total MU of wedged fields (r = 0.59). No significant change in V95% to the cavity was found. CONCLUSIONS: Large translational variations that occur when positioning prone breast patients had small but significant dosimetric effects on 3DCRT plans. Daily CBCT may still be necessary to correct for rotational variations that occur in 20% of treatments. To maintain planned dose metrics, unintended beam shifts toward the heart and the contribution of wedged fields should be minimized.

Single click automated breast planning with iterative optimization.

PURPOSE: To present the development of an in-house coded solution for treatment planning of tangential breast radiotherapy that creates single click plans by emulating the iterative optimization process of human dosimetrists. METHOD: One hundred clinical breast cancer patients were retrospectively planned with an automated planning (AP) code incorporating the hybrid intensity-modulated radiotherapy (IMRT) approach. The code automates all planning processes including plan generation, beam generation, gantry and collimator angle determination, open segments and dynamic IMRT fluence and calculations. Thirty-nine dose volume histogram (DVH) metrics taken from three international recommendations were compared between the automated and clinical plans (CP), along with median interquartile analysis of the DVH distributions. Total planning time and delivery QA were also compared between the plan sets. RESULTS: Of the 39 planning metrics analyzed 23 showed no significant difference between clinical and automated planning techniques. Of the 16 metrics with statistically significant variations, 2 were improved in the clinical plans in comparison to 14 improved in the AP plans. Automated plans produced a greater number of ideal plans against international guidelines as per EviQ (AP:77%, CP:68%), RTOG 1005 (AP:80%, CP:71%), and London Cancer references (AP:80%, CP:75%). Delivery QA results for both techniques were equivalent. Automated planning techniques resulted in an average reduction in planning time from 23 to 5 minutes. CONCLUSION: We have introduced an automated planning code with iterative optimization that produces equivalent quality plans to manual clinical planning. The resultant change in workflow results in a reduction in treatment planning times.

Decision curve analysis apropos of choice of preferable treatment positioning during breast irradiation.

BACKGROUND: Radiotherapy is a standard treatment option for breast cancer, but it may lead to significant late morbidity, including radiation heart damage. Breast irradiation performed individually in the supine or prone position may aid in minimizing the irradiation dose to the heart and LAD coronary artery. A series of CT scans and therapy plans are needed in both positions for the 'gold standard' decision on the preferable treatment position. This method is expensive with respect to technology and physician workload. Our ultimate goal is to develop a predictive tool to identify the preferable treatment position using easily measurable patient characteristics. In this article, we describe the details of how model building and consequently validation of the best model are done. METHODS: Different models were used: both logistic regression and multiple linear regressions were used to estimate the LAD mean dose difference (the difference between the mean dose to the LAD in the supine position versus prone position); predicted dose differences were analysed compared to the 'gold standard' values, and the best model was selected accordingly. The final model was checked by random cross-validation. In addition to generally used measures (ROC and Brier score), decision curves were employed to evaluate the performance of the models. RESULTS: ROC analysis demonstrated that none of the predictors alone was satisfactory. Multiple logistic regression models and the linear regression model lead to high values of net benefit for a wide range of threshold probabilities. Multiple linear regression seemed to be the most useful model. We also present the results of the random cross-validation for this model (i.e. sensitivity of 80.7% and specificity of 87.5%). CONCLUSIONS: Decision curves proved to be useful to evaluate our models. Our results indicate that any of the models could be implemented in clinical practice, but the linear regression model is the most useful model to facilitate the radiation treatment decision. In addition, it is in use in everyday practice in the Department of Oncotherapy, University of Szeged, Hungary.

Patient preferences regarding intraoperative versus external beam radiotherapy for early breast cancer and the impact of socio-demographic factors.

PURPOSE: Patient comfort and preference have steadily gained attention in radio-oncologic treatment of breast cancer. Therefore, the purpose of this investigation was to further explore patient preferences in choosing between intraoperative radiotherapy (IORT) and external beam radiotherapy (EBRT). METHODS: We prospectively analysed data of 101 women, who were candidates for breast-conserving surgery with adjuvant radiotherapy. A two-part video was shown to patients: an educational section about EBRT/IORT, followed by a preference elicitation section focusing on additional accepted risk (AAR) of recurrence after either treatment. Furthermore, participants completed a questionnaire to identify factors that influence patient preference of radiation modality. RESULTS: The data demonstrate that 42.5% of patients would accept additional risk of recurrence for IORT versus 9% AAR for EBRT, while 48.5% of patients would not accept any additional risk, yet would choose IORT over EBRT if risks of recurrence were equivalent. When combining patient preferences and the results from the questionnaire, no single socio-economic/-demographic factor was found to significantly correlate with AAR of IORT. CONCLUSION: Our study confirms the existence of subgroups of breast cancer patients who would accept an additional risk of recurrence associated with choice of radiation modality to receive a single dose of IORT as adjuvant radiotherapy for breast cancer instead of EBRT over several weeks; yet our data fail to identify a single factor significantly associated with these patient preferences and, therefore, helpful for individualised decision-making processes.

Tattoo free setup for partial breast irradiation: A feasibility study.

PURPOSE: Patients undergoing external beam accelerated partial breast irradiation (APBI) receive permanent tattoos to aid with daily setup alignment and verification. With the advent of three-dimensional (3D) body surface imaging and two-dimensional (2D) x-ray imaging-based matching to surgical clips, tattoos may not be necessary to ensure setup accuracy. We compared the accuracy of conventional tattoo-based setups to a patient setup without tattoos. MATERIALS/METHODS: Twenty consecutive patients receiving APBI at our institution from July 10, 2017 to February 13, 2018 were identified. All patients received tattoos per standard of care. Ten patients underwent setup using tattoos for initial positioning followed by surface imaging and 2D matching of surgical clips. The other ten patients underwent positioning using surface imaging followed by 2D matching without reference to tattoos. Overall setup time and orthogonal x-ray-based shifts after surface imaging per fraction were recorded. Shift data were used to calculate systematic and random error. RESULTS: Among ten patients in the "no tattoo" group, the average setup time per fraction was 6.83 min vs 8.03 min in the tattoo cohort (P < 0.01). Mean 3D vector shifts for patients in the "no tattoo" group were 4.6 vs 5.9 mm in the "tattoo" cohort (P = NS). Mean systematic errors in the "no tattoo" group were: 1.2 mm (1.5 mm SD) superior/inferior, 0.5 mm (1.6 mm SD) right/left, and 2.3 mm (1.9 mm SD) anterior/posterior directions. Mean systematic errors in the "tattoo" group were: 0.8 mm (2.2 mm SD) superior/inferior, 0.3 mm (2.5 mm SD) right/left, and 1.4 mm (4.4 mm SD) anterior/posterior directions. The random errors in the "no tattoo" group ranged from 0.6 to 0.7 mm vs 1.2 to 1.7 mm in the "tattoo" group. CONCLUSIONS: Using both surface imaging and 2D matching to surgical clips provides excellent accuracy in APBI patient alignment and setup verification with reduced setup time relative to the tattoo cohort. Skin-based tattoos may no longer be warranted for patients receiving external beam APBI.

Evaluation of interfraction setup variations for postmastectomy radiation therapy using EPID-based in vivo dosimetry.

Postmastectomy radiation therapy is technically difficult and can be considered one of the most complex techniques concerning patient setup reproducibility. Slight patient setup variations - particularly when high-conformal treatment techniques are used - can adversely affect the accuracy of the delivered dose and the patient outcome. This research aims to investigate the inter-fraction setup variations occurring in two different scenarios of clinical practice: at the reference and at the current patient setups, when an image-guided system is used or not used, respectively. The results were used with the secondary aim of assessing the robustness of the patient setup procedure in use. Forty eight patients treated with volumetric modulated arc and intensity modulated therapies were included in this study. EPID-based in vivo dosimetry (IVD) was performed at the reference setup concomitantly with the weekly cone beam computed tomography acquisition and during the daily current setup. Three indices were analyzed: the ratio R between the reconstructed and planned isocenter doses, γ % and the mean value of γ from a transit dosimetry based on a two-dimensional γ -analysis of the electronic portal images using 5% and 5 mm as dose difference and distance to agreement gamma criteria; they were considered in tolerance if R was within 5%, γ % > 90% and γ mean  < 0.4. One thousand and sixteen EPID-based IVD were analyzed and 6.3% resulted out of the tolerance level. Setup errors represented the main cause of this off tolerance with an occurrence rate of 72.2%. The percentage of results out of tolerance obtained at the current setup was three times greater (9.5% vs 3.1%) than the one obtained at the reference setup, indicating weaknesses in the setup procedure. This study highlights an EPID-based IVD system's utility in the radiotherapy routine as part of the patient's treatment quality controls and to optimize (or confirm) the performed setup procedures' accuracy.