Corrigendum to "Two compound techniques for total body irradiation" [Tech. Innov. Patient Support Radiat. Oncol. 21 (2022) 1-7].

[This corrects the article DOI: 10.1016/j.tipsro.2021.11.006.].

Accuracy and potential improvements of surface-guided breast cancer radiotherapy in deep inspiration breath-hold with daily image-guidance.

Objective.Radiotherapy of left-sided breast cancer in deep inspiration breath-hold (DIBH) reduces the heart dose. Surface guided radiotherapy (SGRT) can guide the DIBH, but the accuracy is subject to variations in the chest wall position relative to the patient surface.Approach.In this study, ten left-sided breast cancer patients received DIBH radiotherapy with tangential fields in 15-18 fractions. After initial SGRT setup in free breathing an orthogonal MV/kV image pair was acquired during SGRT-guided breath-hold. The couch was corrected to align the chest wall during another breath-hold, and a new SGRT reference surface was acquired for the gating. The chest wall position error during treatment was determined from continuous cine MV images in the imager direction perpendicular to the cranio-caudal direction. A treatment error budget was made with individual contributions from the online registration of the setup MV image, the difference in breath-hold level between setup imaging and SGRT reference surface acquisition, the SGRT level during treatment, and intra-fraction shifts of the chest wall relative to the SGRT reference surface. In addition to the original setup protocol (Scenario A), SGRT was also simulated with better integration of image-guidance by capturing either the new reference surface (Scenario B) or the SGRT positional signal (Scenario C) simultaneously with the setup MV image, and accounting for the image-guided couch correction by shifting the SGRT reference surface digitally.Main results.In general, the external SGRT signal correlated well with the internal chest wall position error (correlation coefficient >0.7 for 75% of field deliveries), but external-to-internal target position offsets above 2 mm occasionally occurred (13% of fractions). The PTV margin required to account for the treatment error was 3.5 mm (Scenario A), 3.4 mm (B), and 3.1 mm (C).Significance. Further integration of SGRT with image-guidance may improve treatment accuracy and workflow although the current study did not show large accuracy improvements of scenario B and C compared to scenario A.

Two compound techniques for total body irradiation.

INTRODUCTION: Total body irradiation (TBI) is an important treatment modality that is used in combination with chemotherapy in many stem cell transplantation protocols. Therefore, the quality of the irradiation is important. Two techniques for planning and delivering TBI are presented and compared. METHODS AND MATERIALS: The technique named ExIMRT is a combination of manually shaped conventional fields from an extended SSD and isocentric IMRT fields. The technique named ExVMAT is a combination of conventional and IMRT fields from an extended SSD and isocentric VMAT fields. Dosimetric data from 32 patients who were planned and treated according to one of the two techniques were compared. RESULTS: When comparing the two techniques, it is determined that the ExVMAT technique is able to significantly reduce the mean total volume overdosed by 120% from 408 to 12 cm3. The dose covering 98% of the total lung volume is significantly increased by this technique from a mean of 9.7 Gy to 10.3 Gy. Additionally, the dose covering 2% of the total kidney volume is significantly decreased from a mean of 12.8 to 12.5 Gy. Furthermore, the population-based variance of the median dose to the total lung volume, the heart and the volume of the body prescribed to 12.5 Gy is significantly reduced. The results are obtained without compromising overall treatment quality as treatment time or dose rate to the lungs. CONCLUSION: Using the ExVMAT technique, a superior dose distribution can be delivered both from a patient and a population perspective compared to the ExIMRT technique.

Quality assessment of delineation and dose planning of early breast cancer patients included in the randomized Skagen Trial 1.

BACKGROUND AND PURPOSE: To report on a Quality assessment (QA) of Skagen Trial 1, exploring hypofractionation for breast cancer patients with indication for regional nodal radiotherapy. MATERIAL AND METHODS: Deviations from protocol regarding target volume delineations and dose parameters (Dmin, Dmax, D98%, D95% and D2%) from randomly selected dose plans were assessed. Target volume delineation according to ESTRO guidelines was obtained through atlas based automated segmentation and centrally approved as gold standard (GS). Dice similarity scores (DSC) with original delineations were measured. Dose parameters measured in the two delineations were reported to assess their dosimetric outcome. RESULTS: Assessment included 88 plans from 12 centres in 4 countries. DSC showed high agreement in contouring, 99% and 96% of the patients had a complete delineation of target volumes and organs at risk. No deviations in the dosimetric outcome were found in 76% of the patients, 82% and 95% of the patients had successful coverage of breast/chestwall and CTVn_L2-4-interpectoral. Dosimetric outcomes of original delineation and GS were comparable. CONCLUSIONS: QA showed high protocol compliance and adequate dose coverage in most patients. Inter-observer variability in contouring was low. Dose parameters were in harmony with protocol regardless original or GS segmentation.

Dosimetric assessment of an Atlas based automated segmentation for loco-regional radiation therapy of early breast cancer in the Skagen Trial 1: A multi-institutional study.

The effect of Atlas-based automated segmentation (ABAS) on dose volume histogram (DVH) parameters compared to manual segmentation (MS) in loco-regional radiotherapy (RT) of early breast cancer was investigated in patients included in the Skagen Trial 1. This analysis supports implementation of ABAS in clinical practice and multi-institutional trials.

Internal and external validation of an ESTRO delineation guideline - dependent automated segmentation tool for loco-regional radiation therapy of early breast cancer.

BACKGROUND AND PURPOSE: To internally and externally validate an atlas based automated segmentation (ABAS) in loco-regional radiation therapy of breast cancer. MATERIALS AND METHODS: Structures of 60 patients delineated according to the ESTRO consensus guideline were included in four categorized multi-atlas libraries using MIM Maestro™ software. These libraries were used for auto-segmentation in two different patient groups (50 patients from the local institution and 40 patients from other institutions). Dice Similarity Coefficient, Average Hausdorff Distance, difference in volume and time were computed to compare ABAS before and after correction against a gold standard manual segmentation (MS). RESULTS: ABAS reduced the time of MS before and after correction by 93% and 32%, respectively. ABAS showed high agreement for lung, heart, breast and humeral head, moderate agreement for chest wall and axillary nodal levels and poor agreement for interpectoral, internal mammary nodal regions and LADCA. Correcting ABAS significantly improved all the results. External validation of ABAS showed comparable results. CONCLUSIONS: ABAS is a clinically useful tool for segmenting structures in breast cancer loco-regional radiation therapy in a multi-institutional setting. However, manual correction of some structures is important before clinical use. The ABAS is now available for routine clinical use in Danish patients.

Dosimetric verification of complex radiotherapy with a 3D optically based dosimetry system: dose painting and target tracking.

BACKGROUND: The increasing complexity of radiotherapy (RT) has motivated research into three-dimensional (3D) dosimetry. In this study we investigate the use of 3D dosimetry with polymerizing gels and optical computed tomography (optical CT) as a verification tool for complex RT: dose painting and target tracking. MATERIALS AND METHODS: For the dose painting studies, two dosimeters were irradiated with a seven-field intensity modulated radiotherapy (IMRT) plan with and without dose prescription based on a hypoxia image dataset of a head and neck patient. In the tracking experiments, two dosimeters were irradiated with a volumetric modulated arc therapy (VMAT) plan with and without clinically measured prostate motion and a third with both motion and target tracking. To assess the performance, 3D gamma analyses were performed between measured and calculated stationary dose distributions. RESULTS: Gamma pass-rates of 95.3% and 97.3% were achieved for the standard and dose-painted IMRT plans. Gamma pass-rates of 91.4% and 54.4% were obtained for the stationary and moving dosimeter, respectively, while tracking increased the pass-rate for the moving dosimeter to 90.4%. CONCLUSIONS: This study has shown that the 3D dosimetry system can reproduce and thus verify complex dose distributions, also when influenced by motion.

Characterization of the optical properties and stability of Presage™ following irradiation with photons and carbon ions.

BACKGROUND: The on-going development of both intensity-modulated radiotherapy (IMRT), including the more recent intensity-modulated arc therapy, as well as particle beam therapy, has created a clear need for accurate verification of dose distributions in three dimensions (3D). Presage™ is a new 3D dosimetry material that exhibits a radiochromic response when exposed to ionizing radiation. In this study we have 1) developed an improved optical set-up for measurements of changes in OD of Presage™ point dosimeters, 2) investigated the dose response of Presage™ for photons and carbon ions in the therapy range, 3) investigated the dose response of Presage™ for photons in the kGy range and 4) investigated the fading (i.e. bleaching) of Presage™ postirradiation. MATERIALS AND METHODS: Presage™ was examined in 1 × 1 × 4.5 cm(3) optical cuvettes; a cuvette holder assured accurate repositioning, and the optical setup included a reference detector to take into account laser intensity fluctuations. The cuvettes were measured pre- and postirradiation for a two week period. RESULTS: A linear response was observed between dose and optical response between 0 Gy and 100 Gy for γ-radiation from Co-60 and for carbon ions (both plateau and SOBP) from 0 to 20 Gy. The dosimeter was found to have a saturation dose of approximately 100 Gy for photons. A linear energy transfer (LET) effect was not observed in the dose response of different LET radiation. The postirradiation change in optical fading was found to be 0.5% ΔOD/day. CONCLUSIONS: Our study shows that Presage™ remains a dosimeter of interest for radiation therapy with other particles as well as photons in the therapy dose range.

Temperature dependence of the dose response for a solid-state radiochromic dosimeter during irradiation and storage.

PURPOSE: The dose response of radiochromic dosimeters is based on radiation-induced chemical reactions and is thus likely to be thermally influenced. In this study we have therefore investigated the temperature dependence of the dose response for such dosimeters, regarding both irradiation and storage conditions. METHODS: Dosimeter samples in cuvettes were irradiated to 5 Gy. The temperature for the different cuvettes during irradiation and post-irradiation storage was varied in the range of 3-30 degrees C in order to quantify the temperature dependence of the dosimeter response. The optical properties of the dosimeter samples were measured using a spectrophotometer before irradiation as well as at several times after irradiation to quantify the temporal variation of dose response (expressed as the optical density change induced by irradiation) as a function of storage temperature. RESULTS: The measurements show considerable temperature dependencies of dose response both during irradiation and storage. Fit to an Arrhenius equation revealed an activation energy of 1.4 +/- 0.2 eV for the variation in irradiation temperature, indicating a contribution from a thermally activated process. Variation in dose response at different storage temperatures showed an exponential increase with time followed by a decrease in optical density. Exponential Arrhenius fits to rate constants gave activation energies of 1.7 +/- 0.2 eV for the increase in dose response and 2.3 +/- 0.5 eV for the subsequent decrease, in this case dominated by thermally activated processes. CONCLUSIONS: Due to the exponential dependencies, stabilization of the dosimeter during irradiation at low temperatures (e.g., 5 degrees C) is preferable in clinical use to optimize the accuracy of the dose response. In addition, a low storage temperature is recommended in order to minimize the post-irradiation temporal change in dose response and thereby increase the post-irradiation stability of the dosimeter. The measurements in this study show that if the observed temperature and temporal dependencies are not considered, this could potentially deteriorate the accuracy of the dosimeter.