Evaluation of Fused Deposition Modeling Materials for 3D-Printed Container of Dosimetric Polymer Gel.

Accurate dosimetric verification is becoming increasingly important in radiotherapy. Although polymer gel dosimetry may be useful for verifying complex 3D dose distributions, it has limitations for clinical application due to its strong reactivity with oxygen and other contaminants. Therefore, it is important that the material of the gel storage container blocks reaction with external contaminants. In this study, we tested the effect of air and the chemical permeability of various polymer-based 3D printing materials that can be used as gel containers. A methacrylic acid, gelatin, and tetrakis (hydroxymethyl) phosphonium chloride gel was used. Five types of printing materials that can be applied to the fused deposition modeling (FDM)-type 3D printer were compared: acrylonitrile butadiene styrene (ABS), co-polyester (CPE), polycarbonate (PC), polylactic acid (PLA), and polypropylene (PP) (reference: glass vial). The map of R2 (1/T2) relaxation rates for each material, obtained from magnetic resonance imaging scans, was analyzed. Additionally, response histograms and dose calibration curves from the R2 map were evaluated. The R2 distribution showed that CPE had sharper boundaries than the other materials, and the profile gradient of CPE was also closest to the reference vial. Histograms and dose calibration showed that CPE provided the most homogeneous and the highest relative response of 83.5%, with 8.6% root mean square error, compared with the reference vial. These results indicate that CPE is a reasonable material for the FDM-type 3D printing gel container.

Deep learning proton beam range estimation model for quality assurance based on two-dimensional scintillated light distributions in simulations.

BACKGROUND: Many studies have utilized optical camera systems with volumetric scintillators for quality assurances (QA) to estimate the proton beam range. However, previous analytically driven range estimation methods have the difficulty to derive the dose distributions from the scintillation images with quenching and optical effects. PURPOSE: In this study, a deep learning method utilized to QA was used to predict the beam range and spread-out Bragg peak (SOBP) for two-dimensional (2D) map conversion from the scintillation light distribution (LD) into the dose distribution in a water phantom. METHODS: The 2D residual U-net modeling for deep learning was used to predict the 2D water dose map from a 2D scintillation LD map. Monte Carlo simulations for dataset preparation were performed with varying monoenergetic proton beam energies, field sizes, and beam axis shifts. The LD was reconstructed using photons backpropagated from the aperture as a virtual lens. The SOBP samples were constructed based on monoenergetic dose distributions. The training set, including the validation set, consisted of 8659 image pairs of LD and water dose maps. After training, dose map prediction was performed using a 300 image pair test set generated under random conditions. The pairs of simulated and predicted dose maps were analyzed by Bragg peak fitting and gamma index maps to evaluate the model prediction. RESULT: The estimated beam range and SOBP width resolutions were 0.02 and 0.19 mm respectively for varying beam conditions, and the beam range and SOBP width deviations from the reference simulation result were less than 0.1 and 0.8 mm respectively. The simulated and predicted distributions showed good agreement in the gamma analysis, except for rare cases with failed gamma indices in the proximal and field-marginal regions. CONCLUSION: The deep learning conversion method using scintillation LDs in an optical camera system with a scintillator is feasible for estimating proton beam range and SOBP width with high accuracy.

A study of quantitative indicators for slice sorting in cine-mode 4DCT.

The uncertainties of four-dimensional computed tomography (4DCT), also called as residual motion artefacts (RMA), induced from irregular respiratory patterns can degrade the quality of overall radiotherapy. This study aims to quantify and reduce those uncertainties. A comparative study on quantitative indicators for RMA was performed, and based on this, we proposed a new 4DCT sorting method that is applicable without disrupting the current clinical workflow. In addition to the default phase sorting strategy, both additional amplitude information from external surrogates and the quantitative metric for RMA, investigated in this study, were introduced. The comparison of quantitative indicators and the performance of the proposed sorting method were evaluated via 10 cases of breath-hold (BH) CT and 30 cases of 4DCT. It was confirmed that N-RMSD (normalised root-mean-square-deviation) was best matched to the visual standards of our institute's regime, manual sorting method, and could accurately represent RMA. The performance of the proposed method to reduce 4DCT uncertainties was improved by about 18.8% in the averaged value of N-RMSD compared to the default phase sorting method. To the best of our knowledge, this is the first study that evaluates RMA indicators using both BHCT and 4DCT with visual-criteria-based manual sorting and proposes an improved 4DCT sorting strategy based on them.

Fluoroscopy-guided trans-urethral exchange of double-J ureteral stents.

BACKGROUND: For patients with malignant ureteral obstruction or stricture who require long-term internal drainage, plastic double-J stents (DJ stents) represent the mainstay of therapeutic strategies. DJ stents should be replaced at least once every 6 months to avoid infection or obstruction. Although DJ stents are generally replaced under cystoscopy, successful fluoroscopy-guided retrograde replacement of DJ stents in the interventional suite has been described in the literature. METHODS: Between April 2004 and May 2020, we exchanged 143 DJ stents in 19 male and 22 female patients under fluoroscopic guidance using Nelaton catheters, snare catheters, and 8F DJ stents. All procedures were performed with patients under sedation and local anesthesia. There were 39 patients with malignant ureteral obstruction and two patients with benign ureteral strictures. This study was approved by the Institutional Review Board. Technical success, clinical success, complications, procedure time, and mean interval between two procedures were retrospectively reviewed, and the factors affecting the success rate of the procedure were analyzed. RESULTS: Obstruction was detected at the abdominal ureter in 4 patients, pelvic ureter in 29 patients, and intravesical ureter in 8 patients. Twenty-six patients underwent two or more sessions of the procedures, whereas 15 patients underwent single-session procedures. Total 34 outpatient-based procedures and 109 inpatient-based procedures were performed. Technical success and clinical success were achieved in 94.4% (135/143) and 93.3% (126/135) procedures, respectively. Mean procedure time was 21.5 min (range 9-192 min). Mean procedure interval was 101.8 days (range 5-306 days). Technical success was negatively affected by male sex and obstruction at the pelvic ureter and was positively affected by previous successful exchange. Left-sided ureteral stent placement and old age negatively influenced clinical success. Septic shock occurred in one patient and was treated with antibiotics. CONCLUSION: Fluoroscopy-guided trans-urethral exchange of DJ stents is an effective and less painful procedure.

Usefulness of Semi-cylindrical Beam Spoiler in Treatment of Early Glottic Cancer Using 6 MV Photon Beam.

BACKGROUND/AIM: To assess the dosimetric influence of a semi-cylindrical beam spoiler (sCBS) for the treatment of early glottic cancer using a 6 MV photon beam. PATIENTS AND METHODS: The 2D dose distributions were also calculated and measured with and without the sCBS and with a 0.5 cm thick bolus. A retrospective study of 8 patients treated between 2012 and 2018 was performed. RESULTS: The 2D dose distributions obtained from the treatment planning system (TPS) and film measurements were in good agreement. In the planning study, the V95%, V100%, conformal index (CI), and homogeneity index (HI) of all pPTVs for the sCBS plans were better than those for the open field plans (p<0.01). Especially, sCBS plans had better skin sparing effect than bolus plans (p<0.05). CONCLUSION: The sCBS of the 6 MV photon beam could be a useful tool for the treatment of early glottic cancers.

Feasibility of automated planning for whole-brain radiation therapy using deep learning.

PURPOSE: The purpose of this study was to develop automated planning for whole-brain radiation therapy (WBRT) using a U-net-based deep-learning model for predicting the multileaf collimator (MLC) shape bypassing the contouring processes. METHODS: A dataset of 55 cases, including 40 training sets, five validation sets, and 10 test sets, was used to predict the static MLC shape. The digitally reconstructed radiograph (DRR) reconstructed from planning CT images as an input layer and the MLC shape as an output layer are connected one-to-one via the U-net modeling. The Dice similarity coefficient (DSC) was used as the loss function in the training and ninefold cross-validation. Dose-volume-histogram (DVH) curves were constructed for assessing the automatic MLC shaping performance. Deep-learning (DL) and manually optimized (MO) approaches were compared based on the DVH curves and dose distributions. RESULTS: The ninefold cross-validation ensemble test results were consistent with DSC values of 94.6 ± 0.4 and 94.7 ± 0.9 in training and validation learnings, respectively. The dose coverages of 95% target volume were (98.0 ± 0.7)% and (98.3 ± 0.8)%, and the maximum doses for the lens as critical organ-at-risk were 2.9 Gy and 3.9 Gy for DL and MO, respectively. The DL technique shows the consistent results in terms of the DVH parameter except for MLC shaping prediction for dose saving of small organs such as lens. CONCLUSIONS: Comparable with the MO plan result, the WBRT plan quality obtained using the DL approach is clinically acceptable. Moreover, the DL approach enables WBRT auto-planning without the time-consuming manual MLC shaping and target contouring.

Plan optimization with L0-norm and group sparsity constraints for a new rotational, intensity-modulated brachytherapy for cervical cancer.

The aim of this work is to build a framework that comprehends inverse planning procedure and plan optimization algorithm tailored to a novel directional beam intensity-modulated brachytherapy (IMBT) of cervical cancer using a rotatable, single-channel radiation shield. Inverse planning is required for finding optimal beam emitting direction, source dwell position and dwell time, which begin with creating a kernel matrix for each structure based on Monte-Carlo simulated dose distribution in the rotatable shield. For efficient beam delivery and less transit dose, the number of source dwell positions and angles needs to be minimized. It can be solved by L0-norm regularization for fewest possible dwell points, and by group sparsity constraint in L2,p-norm (0≤p<1) besides L0-norm for fewest active applicator rotating angles. The dose distributions from our proposed algorithms were compared to those of conventional tandem-based intracavitary brachytherapy (ICR) plans for six cervical cancer patients. The algorithmic performance was evaluated in delivery efficiency and plan quality relative to the unconstrained algorithm. The proposed framework yielded substantially enhanced plan quality over the conventional ICR plans. The L0-norm and (group sparsity+L0-norm) constrained algorithms reduced the number of source dwell points by 60 and 70% and saved 5 and 8 rotational angles on average (7 and 11 angles for highly modulated cases), relative to the unconstrained algorithm, respectively. Though both algorithms reduced the optimal source dwell positions and angles, the group sparsity constrained optimization with L0-norm was more effective than the L0-norm constraint only, mainly because of considering physical constraints of the new IMBT applicator. With much fewer dwell points compared to the unconstrained, the proposed algorithms led to statistically similar plan quality in dose volume histograms and iso-dose lines. It also demonstrated that the plan optimized by rotating the applicator resulted in much better plan quality than that of conventional applicator-based plans.

Clinical implementation of a wide-field electron arc technique with a scatterer for widespread Kaposi's sarcoma in the distal extremities.

A novel wide-field electron arc technique with a scatterer is implemented for widespread Kaposi's sarcoma (KS) in the distal extremities. Monte Carlo beam modeling for electron arc beams was established to achieve <2% deviation from the measurements, and used for dose calculation. MC-based electron arc plan was performed using CT images of a foot and leg mimicking phantom and compared with in-vivo measurement data. We enrolled one patient with recurrent KS on the lower extremities who had been treated with photon radiation therapy. The 4- and 6-MeV electron arc plans were created, and then compared to two photon plans: two opposite photon beam and volumetric modulated arc with bolus. Compared to the two photon techniques, the electron arc plans resulted in superior dose saving to normal organs beneath the skin region, although it shows inferior coverage and homogeneity for PTV. The electron arc treatment technique with scatterer was successfully implemented for the treatment of widespread KS in the distal extremities with lower radiation exposure to the normal organs beyond the skin lesions, which could be a treatment option for recurrent skin cancer in the extremities.

Abdominal multi-organ auto-segmentation using 3D-patch-based deep convolutional neural network.

Segmentation of normal organs is a critical and time-consuming process in radiotherapy. Auto-segmentation of abdominal organs has been made possible by the advent of the convolutional neural network. We utilized the U-Net, a 3D-patch-based convolutional neural network, and added graph-cut algorithm-based post-processing. The inputs were 3D-patch-based CT images consisting of 64 × 64 × 64 voxels designed to produce 3D multi-label semantic images representing the liver, stomach, duodenum, and right/left kidneys. The datasets for training, validating, and testing consisted of 80, 20, and 20 CT simulation scans, respectively. For accuracy assessment, the predicted structures were compared with those produced from the atlas-based method and inter-observer segmentation using the Dice similarity coefficient, Hausdorff distance, and mean surface distance. The efficiency was quantified by measuring the time elapsed for segmentation with or without automation using the U-Net. The U-Net-based auto-segmentation outperformed the atlas-based auto-segmentation in all abdominal structures, and showed comparable results to the inter-observer segmentations especially for liver and kidney. The average segmentation time without automation was 22.6 minutes, which was reduced to 7.1 minutes with automation using the U-Net. Our proposed auto-segmentation framework using the 3D-patch-based U-Net for abdominal multi-organs demonstrated potential clinical usefulness in terms of accuracy and time-efficiency.

Fluence-map generation for prostate intensity-modulated radiotherapy planning using a deep-neural-network.

A deep-neural-network (DNN) was successfully used to predict clinically-acceptable dose distributions from organ contours for intensity-modulated radiotherapy (IMRT). To provide the next step in the DNN-based plan automation, we propose a DNN that directly generates beam fluence maps from the organ contours and volumetric dose distributions, without inverse planning. We collected 240 prostate IMRT plans and used to train a DNN using organ contours and dose distributions. After training was done, we made 45 synthetic plans (SPs) using the generated fluence-maps and compared them with clinical plans (CP) using various plan quality metrics including homogeneity and conformity indices for the target and dose constraints for organs at risk, including rectum, bladder, and bowel. The network was able to generate fluence maps with small errors. The qualities of the SPs were comparable to the corresponding CPs. The homogeneity index of the target was slightly worse in the SPs, but there was no difference in conformity index of the target, V60Gy of rectum, the V60Gy of bladder and the V45Gy of bowel. The time taken for generating fluence maps and qualities of SPs demonstrated the proposed method will improve efficiency of the treatment planning and help maintain the quality of plans.

Comparing phase- and amplitude-gated volumetric modulated arc therapy for stereotactic body radiation therapy using 3D printed lung phantom.

PURPOSE: To compare the dosimetric impact and treatment delivery efficacy of phase-gated volumetric modulated arc therapy (VMAT) vs amplitude-gated VMAT for stereotactic body radiation therapy (SBRT) for lung cancer by using realistic three-dimensional-printed phantoms. METHODS: Four patient-specific moving lung phantoms that closely simulate the heterogeneity of lung tissue and breathing patterns were fabricated with four planning computed tomography (CT) images for lung SBRT cases. The phantoms were designed to be bisected for the measurement of two-dimensional dose distributions by using EBT3 dosimetry film. The dosimetric accuracy of treatment under respiratory motion was analyzed with the gamma index (2%/1 mm) between the plan dose and film dose measured under phase- and amplitude-gated VMAT. For the validation of the direct usage of the real-time position management (RPM) data for respiratory motion, the relationship between the RPM signal and the diaphragm position was measured by four-dimensional CT. By using data recorded during the beam delivery of both phase- and amplitude-gated VMAT, the total time intervals were compared for each treatment mode. RESULTS: Film dosimetry showed a 5.2 ± 4.2% difference of gamma passing rate (2%/1 mm) on average between the phase- vs amplitude-gated VMAT [77.7% (72.7%-85.9%) for the phase mode and 82.9% (81.4%-86.2%) for the amplitude mode]. For delivery efficiency, frequent interruptions were observed during the phase-gated VMAT, which stopped the beam delivery and required a certain amount of time before resuming the beam. This abnormality in phase-gated VMAT caused a prolonged treatment delivery time of 366 s compared with 183 s for amplitude-gated VMAT. CONCLUSIONS: Considering the dosimetric accuracy and delivery efficacy between the gating methods, amplitude mode is superior to phase mode for gated VMAT treatment.

An additional tilted-scan-based CT metal-artifact-reduction method for radiation therapy planning.

PURPOSE: As computed tomography (CT) imaging is the most commonly used modality for treatment planning in radiation therapy, metal artifacts in the planning CT images may complicate the target delineation and reduce the dose calculation accuracy. Although current CT scanners do provide certain correction steps, it is a common understanding that there is not a universal solution yet to the metal artifact reduction (MAR) in general. Particularly noting the importance of MAR for radiation treatment planning, we propose a novel MAR method in this work that recruits an additional tilted CT scan and synthesizes nearly metal-artifact-free CT images. METHODS: The proposed method is based on the facts that the most pronounced metal artifacts in CT images show up along the x-ray beam direction traversing multiple metallic objects and that a tilted CT scan can provide complementary information free of such metal artifacts in the earlier scan. Although the tilted CT scan would contain its own metal artifacts in the images, the artifacts may manifest in a different fashion leaving a chance to concatenate the two CT images with the metal artifacts much suppressed. We developed an image processing technique that uses the structural similarity (SSIM) for suppressing the metal artifacts. On top of the additional scan, we proposed to use an existing MAR method for each scan if necessary to further suppress the metal artifacts. RESULTS: The proposed method was validated by a simulation study using the pelvic region of an XCAT numerical phantom and also by an experimental study using the head part of the Rando phantom. The proposed method was found to effectively reduce the metal artifacts. Quantitative analyses revealed that the proposed method reduced the mean absolute percentages of the error by up to 86% and 89% in the simulation and experimental studies, respectively. CONCLUSIONS: It was confirmed that the proposed method, using complementary information acquired from an additional tilted CT scan, can provide nearly metal-artifact-free images for the treatment planning.

Dosimetric evaluation of respiratory gated volumetric modulated arc therapy for lung stereotactic body radiation therapy using 3D printing technology.

PURPOSE: This study aimed to evaluate the dosimetric accuracy of respiratory gated volumetric modulated arc therapy (VMAT) for lung stereotactic body radiation therapy (SBRT) under simulation conditions similar to the actual clinical situation using patient-specific lung phantoms and realistic target movements. METHODS: Six heterogeneous lung phantoms were fabricated using a 3D-printer (3DISON, ROKIT, Seoul, Korea) to be dosimetrically equivalent to actual target regions of lung SBRT cases treated via gated VMAT. They were designed to move realistically via a motion device (QUASAR, Modus Medical Devices, Canada). Using the lung phantoms and a homogeneous phantom (model 500-3315, Modus Medical Devices), film dosimetry was performed with and without respiratory gating for VMAT delivery (TrueBeam STx; Varian Medical Systems, Palo Alto, CA, USA). The measured results were analyzed with the gamma passing rates (GPRs) of 2%/1 mm criteria, by comparing with the calculated dose via the AXB and AAA algorithms of the Eclipse Treatment Planning System (version 10.0.28; Varian Medical Systems). RESULTS: GPRs were greater than the acceptance criteria 80% for all film measurements with the stationary and homogeneous phantoms in conventional QAs. Regardless of the heterogeneity of phantoms, there were no significant differences (p > 0.05) in GPRs obtained with and without target motions; the statistical significance (p = 0.031) was presented between both algorithms under the utilization of heterogeneous phantoms. CONCLUSIONS: Dosimetric verification with heterogeneous patient-specific lung phantoms could be successfully implemented as the evaluation method for gated VMAT delivery. In addition, it could be dosimetrically confirmed that the AXB algorithm improved the dose calculation accuracy under patient-specific simulations using 3D printed lung phantoms.

Automated Field-In-Field (FIF) Plan Framework Combining Scripting Application Programming Interface and User-Executed Program for Breast Forward IMRT.

PURPOSE: To develop an one-click option on treatment planning system that enables for the automated breast FIF planning by combining the Eclipse Scripting application programming interfaces and user-executed programming in Windows. METHODS: Scripting application programming interfaces were designed to promote automation in clinical workflow associated with radiation oncology. However, scripting cannot provide all functions that users want to perform. Thus, a new framework proposes to integrate the benefits of the scripting application and user-executed programming for the automated field-in-field technique. We adopted the Eclipse Scripting applications, which provide an interface between treatment planning system server and client and enable for running the executed program to create dose clouds and adjust the planning parameters such as multi-leaf collimator placements and monitor unit values. Importantly, all tasks are designed to perform with one-click option on treatment planning system, including the automated pushback of the proposed plan to the treatment planning system. RESULTS: The plans produced from the proposed framework were validated against the manual field-in-field plans with 40 retrospective breast patient cases in planning efficiency and plan quality. The elapsed time for running the framework was less than 1 minute, which significantly reduced the manual multi-leaf collimator/monitor unit adjustment time. It decreased the total planning time by more than 50%, relative to the manual field-in-field planning. In dosimetric aspects, the mean and maximum dose of the heart, lung, and whole breast did not exceed 1% deviation from the manual plans in most patient cases, while maintaining the target dose coverage and homogeneity index inside the target volume. From numerical analysis, the automated plans were demonstrated to be sufficiently close to the manual plans. CONCLUSION: The combination of scripting applications and user-executed programming for automated breast field-in-field planning accomplished a significant enhancement in planning efficiency without degrading the plan quality, relative to the manual field-in-field procedure.

Evaluation of Hepatic Toxicity after Repeated Stereotactic Body Radiation Therapy for Recurrent Hepatocellular Carcinoma using Deformable Image Registration.

This study aimed to evaluate hepatic toxicity after repeated stereotactic body radiation therapy (SBRT) for recurrent hepatocellular carcinoma (HCC) using deformable image registration (DIR). Between January 2007 and December 2015, 85 patients who underwent two sessions of SBRT for HCC treatment were retrospectively analyzed. A DIR technique was used to calculate the cumulative dose of the first and second SBRT to the normal liver by matching two computed tomography simulation images. The Dice similarity coefficient (DSC) index was calculated to evaluate DIR accuracy. Before the first and second SBRT, 6 (7.1%) and 12 (14.1%) patients were Child-Pugh class B, respectively. Median tumor size was 1.7 cm before both SBRT treatments. Mean DSC index value was 0.93, being >0.9 in 79 (92.9%) registrations. Median cumulative mean liver dose (MLD) was 9.3 Gy (interquartile range, 7.6-11.7). Radiation-induced liver disease developed in three patients, and two of them, with Child-Pugh class B, experienced irreversible liver function deterioration following the second SBRT. The DIR method provided reliable information regarding cumulative doses to the liver. In patients with Child-Pugh class A liver function, repeated SBRT for small recurrent HCC could be safely performed with acceptable hepatic toxicity.

Evaluation of delivered dose to a moving target by 4D dose reconstruction in gated volumetric modulated arc therapy.

PURPOSE: To develop a 4D dose reconstruction method and to evaluate the delivered dose in respiratory-gated volumetric modulated arc therapy (VMAT). MATERIALS AND METHODS: A total 112 treatment sessions of gated VMAT for 30 stereotactic body radiotherapy (SBRT) patients (10 lung, 10 liver, and 10 pancreas) were evaluated. For respiratory-gated SBRT, 4DCT was acquired, and the CT data at the end-exhale phase was used for a VMAT plan. The delivered dose was reconstructed using a patient's respiratory motion and machine motion acquired during the beam delivery. The machine motion was obtained from the treatment log file, while the target position was estimated from an external respiratory marker position. The target position was divided into 1-mm position bins, and sub-beams with beam isocenters corresponding to each position bin were created in a motion mimicking plan, reflecting motion data including MLC leaf positions and gantry angle and target position data during beam treatment. The reconstructed 4D dose was compared with the dose of the original plan using these dosimetric parameters; the maximum dose (Dmax) and mean dose (Dmean) of gross target volume (GTV) or organs at risk (spinal cord, esophagus, heart, duodenum, kidney, spinal cord, and stomach). The minimum dose (Dmin) to GTV was also calculated to verify cold spots in tumors. RESULTS: There was no significant difference of dose parameters regard to the GTV in all tumors. For the liver cases, there were significant differences in the Dmax of duodenum (-4.2 ± 1.4%), stomach (-3.5 ± 4.2%), left kidney (-4.1 ± 2.8%), and right kidney (-3.2 ± 1.3%), and in the Dmean of duodenum (-3.8 ± 1.4%), stomach (-3.9 ± 2.2%), left kidney (-3.1 ± 2.8%), and right kidney (-4.1 ± 2.6%). For the pancreas cases, there were significant differences in the Dmax of stomach (2.1 ± 3.0%), and in the Dmean of liver (1.5 ± 0.6%), duodenum (-1.0 ± 1.4%), stomach (2.1 ± 1.6%), and right kidney (-1.3 ± 0.9%). The average gamma pass rates were 97.6 ± 4.8% for lung cases, 99.6 ± 0.5% for liver cases, and 99.5 ± 0.5% for pancreas cases. Most cases showed insignificant dose variation, with gamma pass rates higher than 98%, except for two lung cases with gamma pass rates of 86.9% and 90.6%. The low gamma pass rates showed larger global motion ranges resulting from the baseline shift during beam delivery. CONCLUSION: The actual delivered dose in thoracic and abdominal VMAT under breathing motion was verified by 4D dose reconstruction using typical treatment equipment and software. The proposed method provides a verification method for the actual delivered dose and could be a dosimetric verification QA tool for radiation treatment under various respiratory management techniques.

Targeting Accuracy of Image-Guided Stereotactic Body Radiation Therapy for Hepatocellular Carcinoma in Real-Life Clinical Practice: In Vivo Assessment Using Hepatic Parenchymal Changes on Gd-EOB-DTPA-Enhanced Magnetic Resonance Images.

PURPOSE: Stereotactic body radiation therapy (SBRT) for hepatocellular carcinoma (HCC) has emerged as an alternative treatment option when curative treatment modalities cannot be applied. Although excellent local tumor control has been achieved with SBRT, the targeting accuracy in real-life practice remains poorly understood. We proposed an in vivo assessment of targeting accuracy using hepatic parenchymal changes observed on gadolinium ethoxybenzyl diethylenetriaminepentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance (MR) images and applied this method to investigate the "real-life" targeting accuracy of image-guided SBRT. METHODS AND MATERIALS: We selected 29 patients with available follow-up MR images acquired 2 to 4 months after completion of SBRT. All patients were administered 45 Gy in 3 fractions. The treated HCC and the region of hepatic parenchymal changes in the hepatobiliary phase of MR images were delineated. We evaluated the discrepancies between the center of the HCC and that of the parenchymal change area (intercenter discrepancy [ICD]). We also analyzed the difference in ICDs between those who underwent SBRT with intrahepatic marker guidance and those with diaphragm guidance. RESULTS: The median ICD in the 3-dimensional direction was 6.81 mm (interquartile range [IQR], 4.27-9.61 mm). Those for the craniocaudal, left-right, and anteroposterior components were 2.70 mm (IQR, 1.83-4.06 mm), 1.63 mm (IQR, 0.76-3.49), and 4.12 mm (IQR, 1.20-6.96 mm), respectively. The median ICD for patients who underwent treatment with intrahepatic marker guidance and those with diaphragm guidance was 7.53 mm (IQR, 6.63-10.86 mm) and 5.60 mm (IQR, 4.28-8.18 mm), respectively. There was no significant difference in ICD between those who underwent treatment with intrahepatic marker guidance and those with diaphragm guidance (P = .296). CONCLUSIONS: The hepatic parenchymal changes observed on Gd-EOB-DTPA-enhanced MR images can be used to assess the targeting accuracy after SBRT for HCC.

Stereotactic body radiation therapy using a respiratory-gated volumetric-modulated arc therapy technique for small hepatocellular carcinoma.

BACKGROUND: Volumetric-modulated arc therapy (VMAT) is a highly sophisticated linear accelerator-based treatment method, and allows dose rate-changing intensity modulation with gantry rotation. We report our clinical experiences with stereotactic body radiation therapy (SBRT) using a respiratory-gated VMAT technique for patients with hepatocellular carcinoma (HCC) when established curative treatments cannot be applied. METHODS: A total of 119 patients (139 lesions) with HCC who were treated with SBRT were registered between March 2012 and July 2013 at our institution. A dose of 10-15 Gy per fraction was applied over 3-4 consecutive days, resulting in a total dose of 30-60 Gy. RESULTS: The median follow-up period was 25.8 months (range, 3.2-36.8 months). The overall 3-year survival rate was 83.8%. The local control rate at 3 years was 97.0% in all treated lesions. Multivariate analysis revealed that the Child-Pugh class before SBRT had significant effects on overall survival (Child-Pugh A: hazard ratio = 0.463; 95% CI, 0.262-0.817; p = 0.008). CONCLUSIONS: SBRT using a respiratory-gated VMAT technique was an excellent ablative treatment modality for patients with HCC. SBRT is a good alternative treatment for patients with small HCCs that are unsuitable for surgical resection or local ablative therapy.

High-dose radiotherapy is associated with better local control of bone metastasis from hepatocellular carcinoma.

We evaluated the pain and radiologic response, time to progression, and dose-response relationship after palliative radiotherapy for bone metastasis from hepatocellular carcinoma. We retrospectively reviewed the medical records of 91 patients between January 2004 and August 2012. The reviewed medical records included data on changes in pain, local tumor progression, and radiologic response evaluated via follow-up images. The radiologic response was assessed based on the Response Evaluation Criteria In Solid Tumors. The pain response was defined according to the International Bone Metastases Consensus Working Party palliative radiotherapy endpoints. Median radiation dose was 40 Gy (range, 20-66 Gy), with various fraction sizes (range, 2.0-6.0 Gy). Pain response rate was 81.4%. During the follow-up periods, radiologic local tumor progression was found in 42 patients (46.2%). The median time to progression was 14.1 months. When the patients were divided into two groups according to their radiation dose (< 55 Gy10 vs. ≥ 55 Gy10), the pain response rates of the high- and low-dose groups did not differ significantly (p = 0.728). However, the radiologic response rate and the time to progression showed significant differences between the two groups (p = 0.009 and p = 0.018, respectively). With dose escalation, higher radiologic response rates and a longer time to progression were achieved in patients with mass-forming bone metastases from hepatocellular carcinoma.

Gated Volumetric-Modulated Arc Therapy vs. Tumor-Tracking CyberKnife Radiotherapy as Stereotactic Body Radiotherapy for Hepatocellular Carcinoma: A Dosimetric Comparison Study Focused on the Impact of Respiratory Motion Managements.

PURPOSE: To assess the potential dosimetric benefits associated with the CyberKnife (CK) tumor tracking capability, wherein an extra margin for respiratory tumor motion is not required, when compared to respiratory-gated volumetric-modulated arc therapy (VMAT) for hepatocellular carcinoma (HCC). METHODS: Twenty-nine HCC patients previously treated with double-arc VMAT were enrolled. In each VMAT plan, the individual internal target volume (ITV) margin around the tumor was determined by measuring its motion over 30-70% of respiratory phases using four-dimensional computed tomography, followed by a 5-mm isotropic margin for the planning target volume (PTV). For each VMAT plan, two CK plans were generated using the original (CKoriginal, ITV included) and modified PTVs (CKmodified, ITV excluded) for comparison. In each case, the CKoriginal and CKmodified plans were compared to the original VMAT plan in terms of the dosimetric parameters including the conformity index (CI), PTV coverage (CO), organs at risk (OAR) doses, and normal liver tissue sparing. RESULTS: The original PTVs with median 24 cc (range, 9-65 cc) were significantly reduced to median 12 cc (range, 5-41 cc) in the CKmodified plans. Statistically significant differences in plan qualities were observed between the VMAT and the CK plans: mean CI, 1.05 in VMAT vs. 1.17 in both CK plans (p < 0.001); and mean CO, 93.0% in VMAT vs. 96.6% in CKoriginal and 96.9% in CKmodified (p < 0.001). The average volume of normal liver tissue receiving > 15 Gy was significantly decreased in the CKmodified plan, as compared to that in the VMAT and CKoriginal plans, by 1.75- and 1.61-fold, respectively. CONCLUSIONS: The tumor tracking capability of the CK system can significantly decrease the volume of normal liver tissue receiving > 15 Gy, while maintaining high precision in target localization, conformity, tumor coverage, and dose sparing of the OAR. Therefore, it can be a valuable SBRT option, particularly for HCC patients with poor liver function.