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This study aimed to evaluate rectal dose reduction in prostate cancer patients who underwent a combination of volumetric modulated arc therapy (VMAT) and low-dose-rate (LDR) brachytherapy with insertion of hydrogel spacer (SpaceOAR). For this study, 35 patients receiving hydrogel spacer and 30 patients receiving no spacer were retrospectively enrolled. Patient was treated to doses of 45 Gy to the primary tumor site and nodal regions over 25 fractions using VMAT and 100 Gy to the prostate using prostate seed implant (PSI). In VMAT plans of patients with no spacer, mean doses of rectal wall were 43.6, 42.4, 40.1, and 28.8 Gy to the volume of 0.5, 1, 2, and 5 cm3 , respectively. In patients with SpaceOAR, average rectal wall doses decreased to 39.0, 36.9, 33.5, and 23.9 Gy to the volume of 0.5, 1, 2, and 5 cm3 , respectively (p < 0.01). In PSI plans, rectal wall doses were on average 78.5, 60.9, 41.8, and 14.8 Gy to the volume of 0.5, 1, 2, and 5 cm3 , respectively, in patients without spacer. In contrast, the doses decreased to 34.5, 28.4, 20.6 (p < 0.01), and 8.5 Gy (p < 0.05) to rectal wall volume of 0.5, 1, 2, and 5 cm3 , respectively, in patient with SpaceOAR. To demonstrate rectal sum dose sparing, dose-biological effective dose (BED) calculation was accomplished in those patients who showed >60% overlap of rectal volumetric doses between VMAT and PSI. In patients with SpaceOAR, average BEDsum was decreased up to 34%, which was 90.1, 78.9, 65.9, and 40.8 Gy to rectal volume of 0.5, 1, 2, and 5 cm3 , respectively, in comparison to 137.4, 116.7, 93.0, and 50.2 Gy to the volume of 0.5, 1, 2, and 5 cm3 , respectively, in those with no spacer. Our result suggested a significant reduction of rectal doses in those patients who underwent a combination of VMAT and LDR with hydrogel spacer placement.
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Neoplasias de la Próstata , Radioterapia de Intensidad Modulada , Humanos , Hidrogeles , Masculino , Neoplasias de la Próstata/patología , Neoplasias de la Próstata/radioterapia , Dosificación Radioterapéutica , Planificación de la Radioterapia Asistida por Computador , Recto , Estudios RetrospectivosRESUMEN
Plan checks are important components of a robust quality assurance (QA) program. Recently, the American Association of Physicists in Medicine (AAPM) published two reports concerning plan and chart checking, Task Group (TG) 275 and Medical Physics Practice Guideline (MPPG) 11.A. The purpose of the current study was to crosswalk initial plan check failure modes revealed in TG 275 against our institutional QA program and local incident reporting data. Ten physicists reviewed 46 high-risk failure modes reported in Table S1.A.i of the TG 275 report. The committee identified steps in our planning process which sufficiently checked each failure mode. Failure modes that were not covered were noted for follow-up. A multidisciplinary committee reviewed the narratives of 1599 locally-reported incidents in our Radiation Oncology Incident Learning System (ROILS) database and categorized each into the high-risk TG 275 failure modes. We found that over half of the 46 high-risk failure modes, six of which were top-ten failure modes, were covered in part by daily contouring peer-review rounds, upstream of the traditional initial plan check. Five failure modes were not adequately covered, three of which concerned pregnancy, pacemakers, and prior dose. Of the 1599 incidents analyzed, 710 were germane to the initial plan check, 23.4% of which concerned missing pregnancy attestations. Most, however, were caught prior to CT simulation (98.8%). Physics review and initial plan check were the least efficacious checks, with error detection rates of 31.8% and 31.3%, respectively, for some failure modes. Our QA process that includes daily contouring rounds resulted in increased upstream error detection. This work has led to several initiatives in the department, including increased automation and enhancement of several policies and procedures. With TG 275 and MPPG 11.A as a guide, we strongly recommend that departments consider an internal chart checking policy and procedure review.
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Oncología por Radiación , Planificación de la Radioterapia Asistida por Computador , Automatización , Humanos , Física , Planificación de la Radioterapia Asistida por Computador/métodos , Gestión de Riesgos/métodosRESUMEN
The SARS-CoV-2 coronavirus pandemic has spread around the world including the United States. New York State has been hardest hit by the virus with over 380 000 citizens with confirmed COVID-19, the illness associated with the SARS-CoV-2 virus. At our institution, the medical physics and dosimetry group developed a pandemic preparedness plan to ensure continued operation of our service. Actions taken included launching remote access to clinical systems for all dosimetrists and physicists, establishing lines of communication among staff members, and altering coverage schedules to limit on-site presence and decrease risk of infection. The preparedness plan was activated March 23, 2020, and data were collected on treatment planning and chart checking efficiency for 6 weeks. External beam patient load decreased by 25% during the COVID-19 crisis, and special procedures were almost entirely eliminated excepting urgent stereotactic radiosurgery or brachytherapy. Efficiency of treatment planning and chart checking was slightly better than a comparable 6-week interval in 2019. This is most likely due to decreased patient load: Fewer plans to generate and more physicists available for checking without special procedure coverage. Physicists and dosimetrists completed a survey about their experience during the crisis and responded positively about the preparedness plan and their altered work arrangements, though technical problems and connectivity issues made the transition to remote work difficult. Overall, the medical physics and dosimetry group successfully maintained high-quality, efficient care while minimizing risk to the staff by minimizing on-site presence. Currently, the number of COVID-19 cases in our area is decreasing, but the preparedness plan has demonstrated efficacy, and we will be ready to activate the plan should COVID-19 return or an unknown virus manifest in the future.
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Betacoronavirus/aislamiento & purificación , Defensa Civil/organización & administración , Infecciones por Coronavirus/epidemiología , Física Sanitaria/organización & administración , Neumonía Viral/epidemiología , Guías de Práctica Clínica como Asunto/normas , Garantía de la Calidad de Atención de Salud , Radiometría/métodos , COVID-19 , Defensa Civil/normas , Infecciones por Coronavirus/terapia , Infecciones por Coronavirus/virología , Física Sanitaria/normas , Humanos , Pandemias , Neumonía Viral/terapia , Neumonía Viral/virología , Factores de Riesgo , SARS-CoV-2 , Estados Unidos/epidemiologíaRESUMEN
Several nomograms exist for ordering palladium-103 seeds for permanent prostate seed implants (PSI). Excess seeds from PSIs pose additional radiation safety risks and increase the cost of care. This study compared five nomograms to clinical data from dynamic modified-peripheral intraoperative PSI to determine (a) the cause of excess seeds and (b) the optimal nomogram for our institution. Pre- and intraoperative patient data were collected for monotherapy PSIs and compiled into a clinical database. All patients were prescribed 125 Gy with dose coverage of D90% = 100% to the planning target volume (PTV) using 103 Pd seeds with mean air-kerma strength ( SK¯ ) of 2 U. Seeds were ordered based upon an in-house nomogram as a function of preoperative prostate volume and prescription dose. Preoperative prostate volume was assessed with transrectal ultrasound. If any of the following four conditions were not met: (a) preoperative volume = intraoperative volume, (b) D90% = 100%, (c) SK¯=2U , and (d) seed ordering matched the in-house nomogram, then a normalization factor was applied to the number of seeds used intraoperatively to meet all four conditions. Four published nomograms, an in-house nomogram, and the normalized number of implanted seeds for each patient were plotted against intraoperative prostate volume. Of the 226 patients, 223 had excess seeds at the completion of their PSI. On average, 25.7 ± 9.9% of ordered seeds were not implanted. Excess seeds were separated into two categories, accounted-for excess, determined by the four normalization factors, and residual excess, assumed to be due to overordering. The upper 99.9% CI linear fit of the normalized clinical data plus a 5% "cushion" may provide a more reasonable nomogram for 103 Pd seed ordering for our institution. Nomograms customized for individual institutions may reduce seed waste, thereby reducing radiation safety risks and increasing the value of prostate brachytherapy.
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Neoplasias de la Próstata/radioterapia , Braquiterapia , Humanos , Radioisótopos de Yodo , Isótopos , Masculino , Paladio , Dosificación Radioterapéutica , Estudios RetrospectivosRESUMEN
Deformable image registration (DIR) and interobserver variation inevitably intro-duce uncertainty into the treatment planning process. The purpose of the current work was to measure deformable image registration (DIR) errors and interobserver variability for regions of interest (ROIs) in the head and neck and pelvic regions. Measured uncertainties were combined to examine planning margin adequacy for contours propagated for adaptive therapy and to assess the trade-off of DIR and interobserver uncertainty in atlas-based automatic segmentation. Two experi-enced dosimetrists retrospectively contoured brainstem, spinal cord, anterior oral cavity, larynx, right and left parotids, optic nerves, and eyes on the planning CT (CT1) and attenuation-correction CT of diagnostic PET/CT (CT2) for 30 patients who received radiation therapy for head and neck cancer. Two senior radiation oncology residents retrospectively contoured prostate, bladder, and rectum on the postseed-implant CT (CT1) and planning CT (CT2) for 20 patients who received radiation therapy for prostate cancer. Interobserver variation was measured by calculating mean Hausdorff distances between the two observers' contours. CT2 was deformably registered to CT1 via commercially available multipass B-spline DIR. CT2 contours were propagated and compared with CT1 contours via mean Hausdorff distances. These values were summed in quadrature with interobserver variation for margin analysis and compared with interobserver variation for sta-tistical significance using two-tailed t-tests for independent samples (α = 0.05). Combined uncertainty ranged from 1.5-5.8 mm for head and neck structures and 3.1-3.7 mm for pelvic structures. Conventional 5 mm margins may not be adequate to cover this additional uncertainty. DIR uncertainty was significantly less than interobserver variation for four head and neck and one pelvic ROI. DIR uncertainty was not significantly different than interobserver variation for four head and neck and one pelvic ROI. DIR uncertainty was significantly greater than interobserver variation for two head and neck and one pelvic ROI. The introduction of DIR errors may offset any reduction in interobserver variation by using atlas-based automatic segmentation.
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Neoplasias de Cabeza y Cuello/diagnóstico por imagen , Variaciones Dependientes del Observador , Tomografía Computarizada por Tomografía de Emisión de Positrones/estadística & datos numéricos , Neoplasias de la Próstata/diagnóstico por imagen , Interpretación de Imagen Radiográfica Asistida por Computador/métodos , Planificación de la Radioterapia Asistida por Computador/métodos , Radioterapia Guiada por Imagen/estadística & datos numéricos , Algoritmos , Neoplasias de Cabeza y Cuello/radioterapia , Humanos , Masculino , Neoplasias de la Próstata/radioterapia , Dosificación Radioterapéutica , Radioterapia de Intensidad Modulada/métodos , Estudios Retrospectivos , IncertidumbreRESUMEN
Substantial disagreement exists over appropriate PET segmentation techniques for non-small cell lung cancer. Currently, no segmentation algorithm explicitly considers tumor motion in determining tumor borders. We developed an automatic PET segmentation model as a function of target volume, motion extent, and source-to-background ratio (the VMSBR model). The purpose of this work was to apply the VMSBR model and six other segmentation algorithms to a sample of lung tumors. PET and 4D CT were performed in the same imaging session for 23 patients (24 tumors) for radiation therapy planning. Internal target volumes (ITVs) were autosegmented on maximum intensity projection (MIP) of cine CT. ITVs were delineated on PET using the following methods: 15%, 35%, and 42% of maximum activity concentration, standardized uptake value (SUV) of 2.5 g/mL, 15% of mean activity concentration plus background, a linear function of mean SUV, and the VMSBR model. Predicted threshold values from each method were compared to measured optimal threshold values, and resulting volume magnitudes were compared to cine-CT-derived ITV. Correlation between predicted and measured threshold values ranged from slopes of 0.29 for the simplest single-threshold techniques to 0.90 for the VMSBR technique. R2 values ranged from 0.07 for the simplest single-threshold techniques to 0.86 for the VMSBR technique. The VMSBR segmentation technique that included volume, motion, and source-to-background ratio, produced accurate ITVs in patients when compared with cine-CT-derived ITV.
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Carcinoma de Pulmón de Células no Pequeñas/radioterapia , Neoplasias Pulmonares/radioterapia , Movimiento , Tomografía de Emisión de Positrones/métodos , Planificación de la Radioterapia Asistida por Computador , Algoritmos , Carcinoma de Pulmón de Células no Pequeñas/diagnóstico por imagen , Carcinoma de Pulmón de Células no Pequeñas/patología , Simulación por Computador , Estudios de Seguimiento , Tomografía Computarizada Cuatridimensional , Humanos , Neoplasias Pulmonares/diagnóstico por imagen , Neoplasias Pulmonares/patología , Fantasmas de Imagen , Pronóstico , Dosificación Radioterapéutica , Estudios RetrospectivosRESUMEN
Purpose: Intermediate- and high-risk prostate cancer patients undergoing combination external beam radiation therapy (EBRT) and low dose rate (LDR) brachytherapy have demonstrated increased genitourinary (GU) toxicity. We have previously demonstrated a method to combine EBRT and LDR dosimetry. In this work, we use this technique for a sample of patients with intermediate- and high-risk prostate cancer, correlate with clinical toxicity, and suggest preliminary summed organ-at-risk constraints for future investigation. Methods and Materials: Intensity modulated EBRT and 103Pd-based LDR treatment plans were combined for 138 patients using biological effective dose (BED) and deformable image registration. GU and gastrointestinal (GI) toxicity were compared with combined dosimetry for the urethra, bladder, and rectum. Differences between doses in each toxicity grade were assessed by analysis of variance (α = 0.05). Combined dosimetric constraints are proposed using the mean organ-at-risk dose, subtracting 1 standard deviation for a conservative recommendation. Results: The majority of our 138-patient cohort experienced grade 0 to 2 GU or GI toxicity. Six grade 3 toxicities were noted. Mean prostate BED D90 (± 1 standard deviation) was 165.5±11.1 Gy. Mean urethra BED D10 was 230.3±33.9 Gy. Mean bladder BED was 35.2±11.0 Gy. Mean rectum BED D2cc was 85.6±24.3 Gy. Significant dosimetric differences between toxicity grades were found for mean bladder BED, bladder D15, and rectum D50, but differences between individual means were not statistically significant. Given the low incidence of grade 3 GU and GI toxicity, we propose urethra D10 <200 Gy, rectum D2cc <60 Gy, and bladder D15 <45 Gy as preliminary dose constraints for combined modality therapy. Conclusions: We successfully applied our dose integration technique to a sample of patients with intermediate- and high-risk prostate cancer. Incidence of grade 3 toxicity was low, suggesting that combined doses observed in this study were safe. We suggest preliminary dose constraints as a conservative starting point to investigate and escalate prospectively in a future study.
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PURPOSE: Combining external beam radiation therapy (EBRT) and prostate seed implant (PSI) is efficacious in treating intermediate- and high-risk prostate cancer at the cost of increased genitourinary toxicity. Accurate combined dosimetry remains elusive due to lack of registration between treatment plans and different biological effect. The current work proposes a method to convert physical dose to biological effective dose (BED) and spatially register the dose distributions for more accurate combined dosimetry. METHODS AND MATERIALS: A PSI phantom was CT scanned with and without seeds under rigid and deformed transformations. The resulting CTs were registered using image-based rigid registration (RI), fiducial-based rigid registration (RF), or b-spline deformable image registration (DIR) to determine which was most accurate. Physical EBRT and PSI dose distributions from a sample of 91 previously-treated combined-modality prostate cancer patients were converted to BED and registered using RI, RF, and DIR. Forty-eight (48) previously-treated patients whose PSI occurred before EBRT were included as a "control" group due to inherent registration. Dose-volume histogram (DVH) parameters were compared for RI, RF, DIR, DICOM, and scalar addition of DVH parameters using ANOVA or independent Student's t tests (αâ¯=â¯0.05). RESULTS: In the phantom study, DIR was the most accurate registration algorithm, especially in the case of deformation. In the patient study, dosimetry from RI was significantly different than the other registration algorithms, including the control group. Dosimetry from RF and DIR were not significantly different from the control group or each other. CONCLUSIONS: Combined dosimetry with BED and image registration is feasible. Future work will utilize this method to correlate dosimetry with clinical outcomes.
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Braquiterapia , Neoplasias de la Próstata , Masculino , Humanos , Próstata , Dosificación Radioterapéutica , Braquiterapia/métodos , Radiometría/métodos , Planificación de la Radioterapia Asistida por Computador/métodos , Neoplasias de la Próstata/diagnóstico por imagen , Neoplasias de la Próstata/radioterapia , AlgoritmosRESUMEN
PURPOSE: Four-dimensional computed tomography (4D-CT) is commonly used to account for respiratory motion of target volumes in radiotherapy to the thorax. From the 4D-CT acquisition, a maximum-intensity projection (MIP) image set can be created and used to help define the tumor motion envelope or the internal gross tumor volume (iGTV). The purpose of this study was to quantify the differences in automatically contoured target volumes for usage in the delivery of stereotactic body radiation therapy using MIP data sets generated from one of the four methods: (1) 4D-CT phase-binned (PB) based on retrospective phase calculations, (2) 4D-CT phase-corrected phase-binned (PC-PB) based on motion extrema, (3) 4D-CT amplitude-binned (AB), and (4) cine CT built from all available images. METHODS: MIP image data sets using each of the four methods were generated for a cohort of 28 patients who had prior thoracic 4D-CT scans that exhibited lung tumor motion of at least 1 cm. Each MIP image set was automatically contoured on commercial radiation treatment planning system. Margins were added to the iGTV to observe differences in the final simulated planning target volumes (PTVs). RESULTS: For all patients, the iGTV measured on the MIP generated from the entire cine CT data set (iGTVcine) was the largest. Expressed as a percentage of iGTVcine, 4D-CT iGTV (all sorting methods) ranged from 83.8% to 99.1%, representing differences in the absolute volume ranging from 0.02 to 4.20 cm3; the largest average and range of 4D-CT iGTV measurements was from the PC-PB data set. Expressed as a percentage of PTVcine (expansions applied to iGTVeine), the 4D-CT PTV ranged from 87.6% to 99.6%, representing differences in the absolute volume ranging from 0.08 to 7.42 cm3. Regions of the measured respiratory waveform corresponding to a rapid change of phase or amplitude showed an increased susceptibility to the selection of identical images for adjacent bins. Duplicate image selection was most common in the AB implementation, followed by the PC-PB method. The authors also found that the image associated with the minimum amplitude measurement did not always correlate with the image that showed maximum tumor motion extent. CONCLUSIONS: The authors identified cases in which the MIP generated from a 4D-CT sorting process under-represented the iGTV by more than 10% or up to 4.2 cm3 when compared to the iGTVcine. They suggest utilization of a MIP generated from the full cine CT data set to ensure maximum inclusive tumor extent.
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Neoplasias/patología , Neoplasias/radioterapia , Radiocirugia/métodos , Planificación de la Radioterapia Asistida por Computador/métodos , Tomografía Computarizada por Rayos X/métodos , Anciano , Anciano de 80 o más Años , Automatización , Femenino , Humanos , Procesamiento de Imagen Asistido por Computador , Masculino , Persona de Mediana Edad , Movimiento (Física) , Neoplasias/diagnóstico por imagen , Radiografía Torácica/métodos , Reproducibilidad de los Resultados , Factores de TiempoRESUMEN
PURPOSE: Hardware integration of fluorodeoxyglucose positron emission tomography (PET) with computed tomography (CT) in combined PET/CT scanners has provided radiation oncologists and physicists with new possibilities for 3-D treatment simulation. The use of PET/CT simulation for target delineation of lung cancer is becoming popular and many studies concerning automatic segmentation of PET images have been performed. Several of these studies consider size and source-to-background (SBR) in their segmentation methods but neglect respiratory motion. The purpose of the current study was to develop a functional relationship between optimal activity concentration threshold, tumor volume, motion extent, and SBR using multiple regression techniques by performing an extensive series of phantom scans simulating tumors of varying sizes, SBR, and motion amplitudes. Segmented volumes on PET were compared with the "motion envelope" of the moving sphere defined on cine CT. METHODS: A NEMA IEC thorax phantom containing six spheres (inner diameters ranging from 10 to 37 mm) was placed on a motion platform and moved sinusoidally at 0-30 mm (at 5 mm intervals) and six different SBRs (ranging from 5:1 to 50:1), producing 252 combinations of experimental parameters. PET images were acquired for 18 min and split into three 6 min acquisitions for reproducibility. The spheres (blurred on PET images due to motion) were segmented at 1% of maximum activity concentration intervals. The optimal threshold was determined by comparing deviations between the threshold volume surfaces with a reference volume surface defined on cine CT. Optimal activity concentration thresholds were normalized to background and multiple regression was used to determine the relationship between optimal threshold, volume, motion, and SBR. Standardized regression coefficients were used to assess the relative influence of each variable. The segmentation model was applied to three lung cancer patients and segmented regions of interest were compared with those segmented on cine CT. RESULTS: The resulting model and coefficients provided a functional form that fit the phantom data with an adjusted R2 = 0.96. The most significant contributor to threshold level was SBR. Surfaces of PET-segmented volumes of three lung cancer patients were within 2 mm of the reference CT volumes on average. CONCLUSIONS: The authors successfully developed an expression for optimal activity concentration threshold as a function of object volume, motion, and SBR.
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Neoplasias Pulmonares/patología , Neoplasias Pulmonares/radioterapia , Tomografía de Emisión de Positrones/métodos , Simulación por Computador , Diseño de Equipo , Fluorodesoxiglucosa F18/farmacología , Humanos , Imagenología Tridimensional , Neoplasias Pulmonares/diagnóstico por imagen , Movimiento (Física) , Movimiento , Fantasmas de Imagen , Dosis de Radiación , Radiografía Torácica/métodos , Dispersión de Radiación , Propiedades de Superficie , Tomografía Computarizada por Rayos X/métodosRESUMEN
Average CT (ACT) and PET have a similar temporal resolution and it has been shown to improve registration of the CT and PET data for PET/CT imaging of the thorax. The purpose of this study was to quantify the effect of ACT attenuation correction on PET for gross tumor volume (GTV) delineation with standardized uptake value (SUV) for liver and esophageal lesions. Our study included 48 colorectal cancer patients with metastasis in the liver and 52 esophageal cancer patients. These patients underwent a routine PET/CT scan followed by a cine CT scan of the thoracic region for ACT. Differences between the two PET data sets (PET HCT and PET ACT ) corrected with the helical CT (HCT) and ACT were quantified by analyzing image alignment, maximum SUV (SUV max ), and GTV. The 67% of the colorectal and 73% of the esophageal studies demonstrated misregistration between the PET HCT and HCT data. ACT was effective in removing misregistration artifacts in 65% of the misregisted colorectal and in 76% of the misregisted esophageal cancer patients. Misregistration between the CT and PET data affected GTVs due to the change in SUV max with ACT. A change of SUV max greater than 20% between PET HCT and PET ACT was found in 15% of the colorectal and 17% of the esophageal cases. Our results demonstrated a more pronounced effect of misregistration for the smaller lesions (< 5 cm 3 ) near the diaphragm (< 5 cm). ACT was effective in improving registration between the CT and PET data in PET/CT for the colorectal and esophageal cancer patients.
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Colonografía Tomográfica Computarizada , Neoplasias Colorrectales/diagnóstico , Neoplasias Esofágicas/diagnóstico , Neoplasias Hepáticas/diagnóstico , Neoplasias Hepáticas/secundario , Tomografía de Emisión de Positrones , Artefactos , Neoplasias Colorrectales/patología , Neoplasias Esofágicas/patología , Humanos , Interpretación de Imagen Asistida por Computador , Imagenología Tridimensional , Radiografía Torácica , Reproducibilidad de los Resultados , Mecánica Respiratoria , Sensibilidad y Especificidad , Tomografía Computarizada EspiralRESUMEN
INTRODUCTION: Studies have suggested that optically stimulated luminescent dosimeters (OSLDs) can be used for in vivo dosimetry of intensity-modulated radiation therapy (IMRT) and volumetric-modulated arc therapy (VMAT). Clinical uncertainties such as placement error have not been thoroughly investigated. The purpose of this work was to measure OSLD placement error in a clinical sample and analyze its dosimetric impact. METHODS AND MATERIALS: The analysis consisted of three parts: first, quantification of placement error in a clinical sample of 128 patients yielding 293 cone-beam CT (CBCT) with visible OSLDs registered to the treatment plan; Second, correlation of placement error and clinical OSLD measurements; third, simulation of dosimeter placement in the treatment plan and correlation of recalculated dose with placement error. RESULTS: In the first analysis, average placement error was 9.7⯱â¯9.5â¯mm. In the second analysis, placement error and measured-to-planned dose agreement yielded no correlation (R2â¯=â¯0.02) for a subsample of 77 CBCTs of 55 head-and-neck patients. Average placement error was 7.0⯱â¯6.0â¯mm. Several factors, including image-guided shifts, introduced uncharacterized uncertainty to the measured-to-planned dose agreement. The third analysis isolated placement error from these other effects. Average dosimetric error was -2.4⯱â¯19.3%. Simulated dosimetric impact was weakly correlated with placement error (R2â¯=â¯0.39). Removing outliers reduced the average dosimetric error to -2.1⯱â¯10.9%, marginally improving the correlation (R2â¯=â¯0.44). CONCLUSION: Placement error can substantially impact measured-to-planned dose agreement of OSLDs in high gradient regions, demonstrating the criticality of accurate dosimeter placement for IMRT and VMAT treatments.
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PURPOSE: Peer review is an essential component of quality assurance programs in radiation oncology. The purpose of this work was to assess whether peer reviewers recommend expansion or reduction of planning target volumes (PTVs) and organs at risk (OARs) in prospective multidisciplinary daily contour rounds. METHODS AND MATERIALS: The peer group evaluated the appropriateness of PTVs and OARs for each case according to evidence-based departmental directives. We reviewed 7645 cases that presented between September 2013 and March 2017. We isolated recommendations for PTV/OAR modification and classified each as expansion, reduction, both, or indeterminate. Recommendations were analyzed by technique, site, and physician experience. RESULTS: Eight junior and 7 senior radiation oncologists were included. PTV or OAR modifications were recommended for 750 of 7645 prescriptions (9.7%). The peer group recommended PTV modifications for 534 prescriptions (7.0%): There were 309 expansions (57.9%), 115 reductions (21.5%), 15 both (2.8%), and 95 indeterminate (17.8%). Reasons for PTV expansions included increased nodal coverage and inadequate margins as a result of motion. The peer group recommended OAR modifications for 216 prescriptions (2.8%): There were 102 expansions (47.2%), 23 reductions (10.6%), 2 both (0.9%), and 89 indeterminate (41.2%). Reasons for OAR expansions included missing critical structures and inadequate extent as per departmental standardization. Head and neck represented the largest percentage of PTV recommendations (28.8%). Intensity modulated radiation therapy plans received the most PTV and OAR recommendations (66.8% and 74.5%, respectively). The recommendation rate for senior and junior faculty was 43% and 28%, respectively. CONCLUSIONS: Peer review resulted in recommendations for PTV or OAR change for approximately 10% of cases. Expansions of PTV were recommended >2.5 times more often than reductions and >3 times more often than OAR expansions. This general trend was identified for treatment technique, site, and physician experience. Prospective peer review could yield systematically larger volumes, which could affect multicenter clinical trials.
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Neoplasias/radioterapia , Revisión por Pares , Garantía de la Calidad de Atención de Salud/métodos , Oncología por Radiación/organización & administración , Planificación de la Radioterapia Asistida por Computador/normas , Algoritmos , Medicina Basada en la Evidencia/organización & administración , Humanos , Órganos en Riesgo , Evaluación de Programas y Proyectos de Salud , Estudios Prospectivos , Traumatismos por Radiación/etiología , Traumatismos por Radiación/prevención & control , Oncólogos de Radiación , Dosificación Radioterapéutica , Planificación de la Radioterapia Asistida por Computador/métodosRESUMEN
This study examined the relationship of achievable mean dose and percent volumetric overlap of salivary gland with the planning target volume (PTV) in volumetric-modulated arc therapy (VMAT) plan in radiotherapy for a patient with head-and-neck cancer. The aim was to develop a model to predict the viability of planning objectives for both PTV coverage and organs-at-risk (OAR) sparing based on overlap volumes between PTVs and OARs, before the planning process. Forty patients with head-and-neck cancer were selected for this retrospective plan analysis. The patients were treated using 6 MV photons with 2-arc VMAT plan in prescriptions with simultaneous integrated boost in dose of 70 Gy, 63 Gy, and 58.1 Gy to primary tumor sites, high-risk nodal regions, and low-risk nodal regions, respectively, over 35 fractions. A VMAT plan was generated using Varian Eclipse (V13.6), in optimization with biological-based generalized equivalent uniform dose (gEUD) objective for OARs and targets. Target dose coverage (D 95, D max, conformity index) and salivary gland dose (D mean and D max) were evaluated in those plans. With a range of volume overlaps between salivary glands and PTVs and dose constraints applied, results showed that dose D 95 for each PTV was adequate to satisfy D 95 >95% of the prescription. Mean dose to parotid <26 Gy could be achieved with <20% volumetric overlap with PTV58 (parotid-PTV58). On an average, the D mean was seen at 15.6 Gy, 21.1 Gy, and 24.2 Gy for the parotid-PTV58 volume at <5%, <10%, and <20%, respectively. For submandibular glands (SMGs), an average D mean of 27.6 Gy was achieved in patients having <10% overlap with PTV58, and 36.1 Gy when <20% overlap. Mean doses on parotid and SMG were linearly correlated with overlap volume (regression R 2 = 0.95 and 0.98, respectively), which were statistically significant (P < 0.0001). This linear relationship suggests that the assessment of the structural overlap might provide prospective for achievable planning objectives in the head-and-neck plan.
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Purpose: To present a retrospective analysis of the efficacy, toxicity, and quality of life (QoL) of patients treated with OAR Extreme -sparing stereotactic body radiotherapy (SBRT) in previously-irradiated head and neck cancer. Materials/Methods: From 11/2012 to 7/2015, 60 patients with in-field recurrence of head and neck cancer underwent re-irradiation with SBRT. Retreatment sites included the aerodigestive tract (43%), lateral neck (22%), and skull base (35%). The median prior RT dose was 63.6 Gy with a median time from prior irradiation of 16.5 months. The median volume treated was 61.0 cc. Patients were treated with 40 Gy in the definitive setting or 35 Gy in the post-operative setting in five fractions. Dose constraints to the OAR Extreme were calculated with a BED calculator using an alpha/beta ratio of 3 to reduce the risk of late toxicities. QoL data was collected from patients at the time of consultation and at subsequent follow up appointments using the MD Anderson Dysphagia Inventory (MDADI) and Symptom Inventory (MDASI). Results: The 1- and 2- year rates of local, regional, and distant control and overall survival were 79/79, 74/70, 74/71, and 59/45%, respectively. Late grade 3 toxicities were seen in 3% in the group treated to the aerodigestive tract and 1% in the group treated to the skull base. No grade 4 or 5 toxicities were observed. Patients with skull base re-irradiation maintained a stable QoL score after radiation treatment, while patients treated to the aerodigestive tract demonstrated a slight impairment associated with worsening dysphagia, compared to their pretreatment baseline. All groups experienced an increase in xerostomia. Conclusions: OAR Extreme -sparing SBRT is able to achieve excellent tumor coverage while protecting the organs at highest risk of re-irradiation-related complications. The potential for lower toxicities and maintained QoL with this treatment makes it a promising option for salvage of recurrent head and neck cancer. SUMMARY: Local control and overall survival rates for recurrent head and neck cancer remain poor, despite the use of local therapy. In addition, re-irradiation with conventional radiation therapy confers a high rate of grade 3 and higher late toxicities. SBRT appears to improve the therapeutic ratio in this patient population, and treatment planning with a focus on sparing OAR Extreme may further decrease the rates of morbidity in these patients.
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Dose calculation for thoracic radiotherapy is commonly performed on a free-breathing helical CT despite artifacts caused by respiratory motion. Four-dimensional computed tomography (4D-CT) is one method to incorporate motion information into the treatment planning process. Some centers now use the respiration-averaged CT (RACT), the pixel-by-pixel average of the ten phases of 4D-CT, for dose calculation. This method, while sparing the tedious task of 4D dose calculation, still requires 4D-CT technology. The authors have recently developed a means to reconstruct RACT directly from unsorted cine CT data from which 4D-CT is formed, bypassing the need for a respiratory surrogate. Using RACT from cine CT for dose calculation may be a means to incorporate motion information into dose calculation without performing 4D-CT. The purpose of this study was to determine if RACT from cine CT can be substituted for RACT from 4D-CT for the purposes of dose calculation, and if increasing the cine duration can decrease differences between the dose distributions. Cine CT data and corresponding 4D-CT simulations for 23 patients with at least two breathing cycles per cine duration were retrieved. RACT was generated four ways: First from ten phases of 4D-CT, second, from 1 breathing cycle of images, third, from 1.5 breathing cycles of images, and fourth, from 2 breathing cycles of images. The clinical treatment plan was transferred to each RACT and dose was recalculated. Dose planes were exported at orthogonal planes through the isocenter (coronal, sagittal, and transverse orientations). The resulting dose distributions were compared using the gamma index within the planning target volume (PTV). Failure criteria were set to 2%/1 mm. A follow-up study with 50 additional lung cancer patients was performed to increase sample size. The same dose recalculation and analysis was performed. In the primary patient group, 22 of 23 patients had 100% of points within the PTV pass y criteria. The average maximum and mean y indices were very low (well below 1), indicating good agreement between dose distributions. Increasing the cine duration generally increased the dose agreement. In the follow-up study, 49 of 50 patients had 100% of points within the PTV pass the y criteria. The average maximum and mean y indices were again well below 1, indicating good agreement. Dose calculation on RACT from cine CT is negligibly different from dose calculation on RACT from 4D-CT. Differences can be decreased further by increasing the cine duration of the cine CT scan.
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Neoplasias Esofágicas/diagnóstico por imagen , Neoplasias Hepáticas/diagnóstico por imagen , Neoplasias Pulmonares/diagnóstico por imagen , Tomografía Computarizada por Rayos X/métodos , Interpretación Estadística de Datos , Neoplasias Esofágicas/diagnóstico , Humanos , Neoplasias Hepáticas/diagnóstico , Neoplasias Pulmonares/diagnóstico , Modelos Estadísticos , Oncología por Radiación/métodos , Interpretación de Imagen Radiográfica Asistida por Computador/métodos , Radiometría , Planificación de la Radioterapia Asistida por Computador/métodos , RespiraciónRESUMEN
PURPOSE: Optically stimulated luminescent dosimeters (OSLDs) are utilized for in vivo dosimetry (IVD) of modern radiation therapy techniques such as intensity modulated radiation therapy (IMRT) and volumetric modulated arc therapy (VMAT). Dosimetric precision achieved with conventional techniques may not be attainable. In this work, we measured accuracy and precision for a large sample of clinical OSLD-based IVD measurements. METHODS AND MATERIALS: Weekly IVD measurements were collected from 4 linear accelerators for 2 years and were expressed as percent differences from planned doses. After outlier analysis, 10,224 measurements were grouped in the following way: overall, modality (photons, electrons), treatment technique (3-dimensional [3D] conformal, field-in-field intensity modulation, inverse-planned IMRT, and VMAT), placement location (gantry angle, cardinality, and central axis positioning), and anatomical site (prostate, breast, head and neck, pelvis, lung, rectum and anus, brain, abdomen, esophagus, and bladder). Distributions were modeled via a Gaussian function. Fitting was performed with least squares, and goodness-of-fit was assessed with the coefficient of determination. Model means (µ) and standard deviations (σ) were calculated. Sample means and variances were compared for statistical significance by analysis of variance and the Levene tests (α = 0.05). RESULTS: Overall, µ ± σ was 0.3 ± 10.3%. Precision for electron measurements (6.9%) was significantly better than for photons (10.5%). Precision varied significantly among treatment techniques (P < .0001) with field-in-field lowest (σ = 7.2%) and IMRT and VMAT highest (σ = 11.9% and 13.4%, respectively). Treatment site models with goodness-of-fit greater than 0.90 (6 of 10) yielded accuracy within ±3%, except for head and neck (µ = -3.7%). Precision varied with treatment site (range, 7.3%-13.0%), with breast and head and neck yielding the best and worst precision, respectively. Placement on the central axis of cardinal gantry angles yielded more precise results (σ = 8.5%) compared with other locations (range, 10.5%-11.4%). CONCLUSIONS: Accuracy of ±3% was achievable. Precision ranged from 6.9% to 13.4% depending on modality, technique, and treatment site. Simple, standardized locations may improve IVD precision. These findings may aid development of patient-specific tolerances for OSLD-based IVD.
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Dosimetría in Vivo , Neoplasias/radioterapia , Dosimetría con Luminiscencia Ópticamente Estimulada/instrumentación , Dosímetros de Radiación , Radioterapia Conformacional/instrumentación , Exactitud de los Datos , Femenino , Humanos , Masculino , Modelos Teóricos , Distribución Normal , Dosificación Radioterapéutica , Radioterapia de Intensidad Modulada/instrumentación , Estudios RetrospectivosRESUMEN
PURPOSE: Our purpose was to evaluate hippocampal doses and target volume coverage with and without hippocampal sparing when treating multiple brain metastases using various stereotactic radiosurgery (SRS) platforms. METHODS AND MATERIALS: We selected 10 consecutive patients with 14 separate treatments who had been treated in our department for 3 to 10 brain metastases and added hippocampal avoidance contours. All 14 treatments were planned with GammaPlan for Gamma Knife, Eclipse for single isocenter volumetric modulated arc therapy (VMAT), TomoTherapy Treatment Planning System (TPS) for TomoTherapy, and MultiPlan for CyberKnife. Initial planning was performed with the goal of planning target volume coverage of V100 ≥95% without hippocampal avoidance. If the maximum hippocampal point dose (Dmax) was <6.6 Gy in a single fraction and <40% of the hippocampi received ≤4.5 Gy, no second plan was performed. If either constraint was not met, replanning was performed with these constraints. RESULTS: There was a median of 6 metastases per plan, with an average total tumor volume of 7.32 mL per plan. The median hippocampal Dmax (in Gy) without sparing averaged 1.65, 9.81, 4.38, and 5.46, respectively (P < .0001). Of 14 plans, 3 Gamma Knife and CyberKnife plans required replanning, whereas 13 VMAT and 8 TomoTherapy plans required replanning. The hippocampal constraints were not achievable in 1 plan on any platform when the tumor was bordering the hippocampus. The mean volume of brain receiving 12 Gy (in mL), which has been associated with symptomatic radionecrosis, was 23.57 with Gamma Knife, 76.77 with VMAT, 40.86 with CyberKnife, and 104.06 with TomoTherapy (P = .01). The overall average conformity indices for all plans ranged from 0.36 to 0.52. CONCLUSIONS: Even with SRS, the hippocampi can receive a considerable dose; however, if the hippocampi are outlined as organs of risk, sparing these structures is feasible in nearly all situations with all 4 platforms, without detriment to target coverage, and should be considered in all patients undergoing SRS for multiple brain metastases. SUMMARY: Hippocampi play an important role in memory, and sparing of these structures in whole brain radiation can improve neurocognitive outcomes. The hippocampi are not routinely spared when using stereotactic radiosurgery. We evaluated the incidental dose to the hippocampi when treating multiple brain metastases and sought to examine if hippocampal sparing is feasible without detriment to target coverage. We found that hippocampal sparing is possible without affecting coverage or conformality in most cases across treatment platforms.
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Neoplasias Encefálicas/radioterapia , Hipocampo , Tratamientos Conservadores del Órgano/métodos , Radiocirugia/métodos , Radioterapia de Intensidad Modulada/métodos , Neoplasias Encefálicas/patología , Neoplasias Encefálicas/secundario , Hipocampo/efectos de la radiación , Humanos , Radiocirugia/efectos adversos , Dosificación Radioterapéutica , Planificación de la Radioterapia Asistida por Computador/métodos , Radioterapia de Intensidad Modulada/efectos adversos , Resultado del Tratamiento , Carga Tumoral/efectos de la radiaciónRESUMEN
PURPOSE: To assess the need for gross tumor volume (GTV) delineation protocols in head-and-neck cancer (HNC) treatment planning by use of positron emission tomography (PET)/computed tomography (CT) fusion imaging. Assessment will consist of interobserver and intermodality variation analysis. METHODS AND MATERIALS: Sixteen HNC patients were accrued for the study. Four physicians (2 neuroradiologists and 2 radiation oncologists) contoured GTV on 16 patients. Physicians were asked to contour GTV on the basis of the CT alone, and then on PET/CT fusion. Statistical analysis included analysis of variance for interobserver variability and Student's paired sample t test for intermodality and interdisciplinary variability. A Boolean pairwise analysis was included to measure degree of overlap. RESULTS: Near-significant variation occurred across physicians' CT volumes (p = 0.09) and significant variation occurred across physicians' PET/CT volumes (p = 0.0002). The Boolean comparison correlates with statistical findings. One radiation oncologist's PET/CT fusion volumes were significantly larger than his CT volumes (p < 0.01). Conversely, the other radiation oncologist's CT volumes tended to be larger than his fusion volumes (p = 0.06). No significant interdisciplinary variation was seen. Significant disagreement occurred between radiation oncologists. CONCLUSION: Significant differences in GTV delineation were found between multiple observers contouring on PET/CT fusion. The need for delineation protocol has been confirmed.
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Neoplasias de Cabeza y Cuello/diagnóstico por imagen , Tomografía de Emisión de Positrones/métodos , Tomografía Computarizada por Rayos X/métodos , Adulto , Anciano , Anciano de 80 o más Años , Análisis de Varianza , Femenino , Fluorodesoxiglucosa F18 , Humanos , Masculino , Persona de Mediana Edad , Variaciones Dependientes del Observador , RadiofármacosRESUMEN
To compare relative carotid and normal tissue sparing using volumetric-modulated arc therapy (VMAT) or intensity-modulated radiation therapy (IMRT) for early-stage larynx cancer. Seven treatment plans were retrospectively created on 2 commercial treatment planning systems for 11 consecutive patients with T1-2N0 larynx cancer. Conventional plans consisted of opposed-wedged fields. IMRT planning used an anterior 3-field beam arrangement. Two VMAT plans were created, a full 360° arc and an anterior 180° arc. Given planning target volume (PTV) coverage of 95% total volume at 95% of 6300 cGy and maximum spinal cord dose below 2500 cGy, mean carotid artery dose was pushed as low as possible for each plan. Deliverability was assessed by comparing measured and planned planar dose with the gamma (γ) index. Full-arc planning provided the most effective carotid sparing but yielded the highest mean normal tissue dose (where normal tissue was defined as all soft tissue minus PTV). Static IMRT produced next-best carotid sparing with lower normal tissue dose. The anterior half-arc produced the highest carotid artery dose, in some cases comparable with conventional opposed fields. On the whole, carotid sparing was inversely related to normal tissue dose sparing. Mean γ indexes were much less than 1, consistent with accurate delivery of planned treatment. Full-arc VMAT yields greater carotid sparing than half-arc VMAT. Limited-angle IMRT remains a reasonable alternative to full-arc VMAT, given its ability to mediate the competing demands of carotid and normal tissue dose constraints. The respective clinical significance of carotid and normal tissue sparing will require prospective evaluation.