Capecitabine-Induced Ileitis during Neoadjuvant Pelvic Radio-Chemotherapy for Locally Advanced Rectal Cancer: A Case Report with Literature Review.

We report on a clinical case of capecitabine-induced acute ileitis in a patient treated with pre-operative concurrent chemoradiation with capecitabine for locally advanced rectal cancer and provide a comprehensive literature review. This a rare, but life-threatening, clinical situation, that clinicians should be aware of. Severe persistent diarrhea is the most frequent clinical feature and computed tomography is a valid tool for diagnosis. Conservative management includes capecitabine withdrawal, antidiarrheal therapy and endovenous hydration, together with dietary modifications and broad-spectrum antibiotics. Pelvic irradiation represents an adjunctive risk factor, which may increase the likelihood of occurrence of terminal ileitis. Early recognition and prompt intervention are crucial for successful clinical management.

Application of a smart 18F-FDG-PET adaptive threshold segmentation algorithm for the biological target volume delineation in head and neck cancer.

BACKGROUND: The aim of the present study is to evaluate the reliability of a 18F-fluorodeoxyglucose (18F-FDG) PET adaptive threshold segmentation (ATS) algorithm, previously validated in a preclinical setting on several scanners, for the biological target volume (BTV) delineation of head and neck radiotherapy planning. METHODS: [18F]FDG PET ATS algorithm was studied in treatment plans of head and neck squamous cell carcinoma on a dedicated workstation (iTaRT, Tecnologie Avanzate, Turin, Italy). BTVs segmented by the present ATS algorithm (BTVATS) were compared with those manually segmented for the original radiotherapy treatment planning (BTVVIS). We performed a qualitative and quantitative volumetric analysis with a comparison tool within the ImSimQA TM software package (Oncology Systems Limited, Shrewsbury, UK). We reported figures of merit (FOMs) to convey complementary information: Dice Similarity Coefficient, Sensitivity Index, and Inclusiveness Index. RESULTS: The study was conducted on 32 treatment plans. Median BTVATS was 11 cm3 while median BTVVIS was 14 cm3. The median Dice Similarity Coefficient, Sensitivity Index, Inclusiveness Index were 0.72, 63%, 88%, respectively. Interestingly, the median volume and the median distance of the voxels that are over contoured by ATS were respectively 1 cm3 and 1 mm. CONCLUSIONS: ATS algorithm could be a smart and an independent operator tool when implemented for 18F-FDG-PET-based tumor volume delineation. Furthermore, it might be relevant in case of BTV-based dose painting.

Stereotactic ablative radiotherapy for oligometastatic prostate cancer.

Background: The present study assessed clinical outcomes of stereotactic body radiotherapy (SBRT) in oligometastatic prostate cancer patients. Materials and methods: Between 2017 and 2020, 37 lesions (12 osseous and 25 nodal targets) detected with conventional and/or functional imaging, were treated in 29 patients (pts), in different clinical settings: de novo oligometastatic (2 pts), oligorecurrent castration-sensitive (19 pts), castration-resistant (6 pts) prostate cancers and oligoprogressive disease during systemic therapy (2 pts). SBRT was delivered with volumetric modulated arc therapy up to a total dose of 21 Gy given in 3 fractions for bone and 30 Gy in 5 fractions for nodal metastases. A total of 34% of pts received hormonal therapy. We evaluated biochemical control [prostate serum antigen (PSA) increase < 10%)], progression free-survival (PFS) (time from SBRT to biochemical progression), local control (LC) (time from SBRT to in-field radiologic progression), hormone/systemic therapy-free survival, acute and late toxicities. Results: At 3 months, biochemical response was observed in 20/29 pts (69%). At a median follow-up of 17 months (range 6-33), 8/20 (40%) of the 3-month responders remained free from progression. Two-year PFS and LC were 37% and 70%, respectively. In-field progression occurred in 3/37 (8%) lesions. Hormone/systemic therapy was delayed by an average of 11.6 months (range 3-28). No significant difference in PFS based on the type of lesion or concomitant endocrine therapy was observed and no toxicity > grade 2 was reported. Conclusions: SBRT for oligometastatic prostate cancer offers a good biochemical/local control and tangible delay of hormone/systemic therapy without major toxicities.

Ultra-Hypofractionation for Whole-Breast Irradiation in Early Breast Cancer: Interim Analysis of a Prospective Study.

We report on the early clinical outcomes of a prospective series of early breast cancer (EBC) patients treated with ultra-hypofractionated post-operative whole-breast irradiation (WBI) after breast-conserving surgery (BCS) and axillary management. Primary endpoints were patient's compliance and acute toxicity. Secondary endpoints included physician-rated cosmesis and ipsilateral breast tumour recurrence (IBTR). Acute toxicity was evaluated at the end of WBI, 3 weeks and 6 months thereafter, according to the Common Terminology Criteria for Adverse Events (v. 5.0). Patients were treated between September 2021 and May 2022. The treatment schedule for WBI consisted of either 26 Gy in 5 fractions over one week (standard approach) or 28.5 Gy in 5 fractions over 5 weeks (reserved to elders). Inverse planned intensity-modulated radiation therapy (IMRT) was used employing a static technique. A total of 70 patients were treated. Fifty-nine were treated with the 26 Gy/5 fr/1 w and 11 with the 28.5 Gy/5 fr/5 ws schedule. Median age was 67 and 70 in the two groups. Most of the patients had left-sided tumours (53.2%) in the 26 Gy/5 fr/1 w or right-sided lesions (63.6%) in the 28.5 Gy/5 fr/5 ws group. Most of the patients had a clinical T1N0 disease and a pathological pT1pN0(sn) after surgery. Ductal invasive carcinoma was the most frequent histology. Luminal A intrinsic subtyping was most frequent. Most of the patients underwent BCS and sentinel lymph node biopsy and adjuvant endocrine therapy. All patients completed the treatment program as planned. Maximum detected acute skin toxicities were grade 2 erythema (6.7%), grade 2 induration (4.4%), and grade 2 skin colour changes. No early IBTR was observed. Ultra-hypofractionated WBI provides favourable compliance and early clinical outcomes in EBC after BCS in a real-world setting.

Urinary toxicity in patients treated with radical EBRT for prostate cancer: Analysis of predictive factors in an historical series.

AIM AND BACKGROUND: The present study aims to identify predictive factors for urinary toxicity and self-reported symptoms after external beam radiotherapy (EBRT) for prostate cancer. METHODS: Two-hundred and eighty patients treated with EBRT for prostate cancer were included in the present study. Toxicity was scored following the grading system based on Radiation Therapy Oncology Group (RTOG) scale. International Prostatic Symptom Score (IPSS) and Consultation on Incontinence Questionnaires - Short Form (ICIQ-SF) were used to analyse self-reported symptoms. Acute and late urinary toxicities were correlated to clinical and treatment parameters, radiation dosimetry data, IPSS and ICIQ-SF. RESULTS: Median patient age was 74 years (range, 64-83). Thirty-one percent experienced acute G1 urinary toxicity, 24% G2 and 3% G3. Fourteen percent experienced G1 late urinary toxicity and 3% G2. Bladder volume<200 cc was associated with acute urinary toxicity (P=0.014); use of MRI for treatment planning allowed a lower incidence of late toxicity (P=0.062) and use of IMRT allowed for reduced incidence in late toxicity (P=0.038). Maximum bladder dose correlated with late urinary toxicity (P=0.014). The analysis of self-reported symptoms showed a significant correlation between IPSS baseline values (P=0.009), presence of nocturia (P=0.002), bladder urgency (P=0.024) and incontinence (P=0.024) and development of acute urinary toxicity at univariate analysis. At multivariate logistic regression analysis, bladder filling, IPSS value, nocturia, and urinary incontinence retained significant correlation with acute toxicity (P=0.0003). DISCUSSION: Significant independent predictors for acute urinary toxicity grade≥2 were bladder filling, IPSS value, nocturia, and urinary incontinence at baseline assessment.

Implementation of automatic plan optimization in Italy: Status and perspectives.

PURPOSE: To investigate and report on the diffusion and clinical use of automated radiotherapy planning systems in Italy and to assess the perspectives of the community of Italian medical physicists involved in radiotherapy on the use of these tools. MATERIALS AND METHODS: A survey of medical physicists (one per Institute) of 175 radiotherapy centers in Italy was conducted between February 21st and April 1st, 2021. The information collected included the institute's characteristics, plan activity, availability/use of automatic tools and related issues regarding satisfaction, criticisms, expectations, and perceived professional modifications. Responses were analysed, including the impact of a few variables such as the institute type and experience. RESULTS: 125 of the centers (71%) answered the survey, with regional variability (range: 47%-100%); among these, 49% have a TPS with some automatic option. Clinical use of automatic planning is present in 33% of the centers, with 13% applying it in >50% of their plans. Among the 125 responding centres the most used systems are Pinnacle (16%), Raystation (9%) and Eclipse (4%). The majority of participants consider the use of automated techniques to be beneficial, while only 1% do not see any advantage; 83% of respondents see the possibility of enriching their professional role as a potential benefit, while 3% see potential threats. CONCLUSIONS: Our survey shows that 49% of the responding centres have an automatic planning solution although clinically used in only 33% of the cases. Most physicists consider the use of automated techniques to be beneficial and show a prevalently positive attitude.

Adaptive Strategy for External Beam Radiation Therapy in Prostate Cancer: Management of the Geometrical Uncertainties With Robust Optimization.

PURPOSE: We aim to develop and validate a new adaptive method for prostate cancer radiation therapy (RT), using an offline strategy to improve treatment personalization by modeling the internal target volume on individual basis and account for the residual set-up uncertainties by robust optimization. METHODS AND MATERIALS: Twenty patients with intermediate-high prostate cancer treated with radical radiation therapy were enrolled. The first step of the offline adaptive RT strategy is the identification of a patient-specific internal target volume based on the kV cone beam computed tomography (kV-CBCT) data sets acquired during the first 5 fractions. The deformable image registration algorithm ANACONDA was used to propagate the clinical target volumes (CTVs) from the reference-planning computed tomography to the CBCTs; these contours were assessed by a radiation oncologist. In the second step, the internal target volume was used to replan the treatment using a min-max robust algorithm based on the worst scenario optimization. The CTV coverage and organs-at-risk sparing achieved with the robust plan (RP) were analyzed and compared with the original standard plan, calculating the dose distributions on the residual CBCTs. RESULTS: The RP was shown to achieve optimal coverage of the CTV even in the worst scenario, with significantly lower doses to the rectum and bladder. CTV coverage of the RP was statistically better than the standard plan in terms of D99 (P = .008) and D98 (P = .02). Statistically significant mean dose reduction and D2 reduction were noted for the rectum (P < .05) and bladder (P < .009). Moreover, the RP appeared to be less sensitive to bladder and rectal filling. CONCLUSIONS: This adaptive strategy in prostate cancer radiation therapy is feasible and safe; it may be used to adapt the treatment with better target coverage and organs-at-risk sparing than standard planning target volume-based planning.

Automatic genetic planning for volumetric modulated arc therapy: A large multi-centre validation for prostate cancer.

PURPOSE: The first clinical genetic autoplanning algorithm (Genetic Planning Solution, GPS) was validated in ten radiotherapy centres for prostate cancer VMAT by comparison with manual planning (Manual). METHODS: Although there were large differences among centres in planning protocol, GPS was tuned with the data of a single centre and then applied everywhere without any centre-specific fine-tuning. For each centre, ten Manual plans were compared with autoGPS plans, considering dosimetric plan parameters and the Clinical Blind Score (CBS) resulting from blind clinician plan comparisons. AutoGPS plans were used as is, i.e. there was no patient-specific fine-tuning. RESULTS: For nine centres, all ten plans were clinically acceptable. In the remaining centre, only one plan was acceptable. For the 91% acceptable plans, differences between Manual and AutoGPS in target coverage were negligible. OAR doses were significantly lower in AutoGPS plans (p < 0.05); rectum D15% and Dmean were reduced by 8.1% and 17.9%, bladder D25% and Dmean by 5.9% and 10.3%. According to clinicians, 69% of the acceptable AutoGPS plans were superior to the corresponding Manual plan. In case of preferred Manual plans (31%), perceived advantages compared to autoGPS were minor. QA measurements demonstrated that autoGPS plans were deliverable. A quick configuration adjustment in the centre with unacceptable plans rendered 100% of plans acceptable. CONCLUSION: A novel, clinically applied genetic autoplanning algorithm was validated in 10 centres for in total 100 prostate cancer patients. High quality plans could be generated at different centres without centre-specific algorithm tuning.

Apoptotic and predictive factors by Bax, Caspases 3/9, Bcl-2, p53 and Ki-67 in prostate cancer after 12 Gy single-dose.

Radio-induced apoptosis is mediated by the activation of tumor protein p53, Bax and caspases. The purpose of this study was to investigate the early activation of this pathway in men receiving in vivo irradiation immediately before radical prostatectomy for locally advanced prostate cancer. We also investigated cell proliferation index (Ki-67), proto-oncogene (p53) and anti-apoptotic protein (Bcl-2) levels as potential predictive factors. We selected a homogeneous sample of 20 patients with locally advanced prostate cancer and candidate to radical prostatectomy. To assess the apoptotic pathways, Bax, is studied through immunofluorescence assay, before and after 12 Gy single dose intraoperative radiotherapy (IORT) to the prostate, on bioptic samples and on surgical specimens. Moreover, before and after IORT, Bcl-2, p53, and Ki-67 were also detected through immunohistochemistry. A count of positive Bax spots for immunofluorescence was performed on tumor cells, prostatic intraepithelial neoplasia (PIN), and healthy tissue areas before and after IORT. We also analyzed Caspases 3 and 9 expressions after IORT. Before IORT, Bcl-2 mean value in neoplastic cells was 2.23% ± 1.95, mean Ki-67 in neoplastic area was 4.5% ± 3.8, and p53 was 22.5% ± 6.8. After IORT, Bcl-2 mean value in neoplastic cells was 8.85 ± 8.92%, Ki-67 in neoplastic area was 7.8 ± 6.09%, and p53 was 24.9 ± 26.4%. After the irradiation, healthy areas expressed significantly lower levels of Bax (2.81 ± 1.69%) with respect to neoplastic cells (p < 0.0001), while in PIN areas, Bax positive cells were significantly more present than in neoplastic areas (p = 0.0001). At statistical analysis, it was observed that cancer cells with Ki-67 ≥ 8% had a trend toward greater expression of Bax (p = 0.0641). We observed an increase of Bcl-2 expression after IORT in neoplastic areas (p = 0.0041). Biopsy specimens with p53 ≥ 18% and Ki-67 ≥ 8% had worse post-operative staging with extracapsular invasion (p = 0.04 for both parameters) and nodal positivity (p = 0.04 for p53 and p = 0.0001 at pathology for ki-67). No correlation between IORT and Caspases activation was noted. In conclusion, after 12 Gy IORT, Bax was overexpressed in tumor and PIN cells. Pre-operative Ki-67 and p53 definition could be used in future studies to predict patients with worse pathological stage, while Bcl-2 activation after IORT might be a predictive factor for loco-regional failure.

Computed Tomography to Cone Beam Computed Tomography Deformable Image Registration for Contour Propagation Using Head and Neck, Patient-Based Computational Phantoms: A Multicenter Study.

PURPOSE: To investigate the performance of various algorithms for deformable image registration (DIR) for propagating regions of interest (ROIs) using multiple commercial platforms, from computed tomography to cone beam computed tomography (CBCT) and megavoltage computed tomography. METHODS AND MATERIALS: Fourteen institutions participated in the study using 5 commercial platforms: RayStation (RaySearch Laboratories, Stockholm, Sweden), MIM (Cleveland, OH), VelocityAI and SmartAdapt (Varian Medical Systems, Palo Alto, CA), and ABAS (Elekta AB, Stockholm, Sweden). Algorithms were tested on synthetic images generated with the ImSimQA (Oncology Systems Limited, Shrewsbury, UK) package by applying 2 specific deformation vector fields (DVF) to real head and neck patient datasets. On-board images from 3 systems were used: megavoltage computed tomography from Tomotherapy and 2 kinds of CBCT from a clinical linear accelerator. Image quality of the system was evaluated. The algorithms' accuracy was assessed by comparing the DIR-mapped ROIs returned by each center with those of the reference, using the Dice similarity coefficient and mean distance to conformity metrics. Statistical inference on the validation results was carried out to identify the prognostic factors of DIR performance. RESULTS: Analyzing 840 DIR-mapped ROIs returned by the centers, it was demonstrated that DVF intensity and image quality were significant prognostic factors of DIR performance. The accuracy of the propagated contours was generally high, and acceptable DIR performance can be obtained with lower-dose CBCT image protocols. CONCLUSIONS: The performance of the systems proved to be image quality specific, depending on the DVF type and only partially on the platforms. All systems proved to be robust against image artifacts and noise, except the demon-based software.

Performance of commercially available deformable image registration platforms for contour propagation using patient-based computational phantoms: A multi-institutional study.

PURPOSE: To investigate the performance of various algorithms for deformable image registration (DIR) to propagate regions of interest (ROIs) using multiple commercial platforms. METHODS AND MATERIALS: Thirteen institutions participated in the study with six commercial platforms: RayStation (RaySearch Laboratories, Stockholm, Sweden), MIM (Cleveland, OH, USA), VelocityAI and Smart Adapt (Varian Medical Systems, Palo Alto, CA, USA), Mirada XD (Mirada Medical Ltd, Oxford, UK), and ABAS (Elekta AB, Stockholm, Sweden). The DIR algorithms were tested on synthetic images generated with the ImSimQA package (Oncology Systems Limited, Shrewsbury, UK) by applying two specific Deformation Vector Fields (DVF) to real patient data-sets. Head-and-neck (HN), thorax, and pelvis sites were included. The accuracy of the algorithms was assessed by comparing the DIR-mapped ROIs from each center with those of reference, using the Dice Similarity Coefficient (DSC) and Mean Distance to Conformity (MDC) metrics. Statistical inference on validation results was carried out in order to identify the prognostic factors of DIR performances. RESULTS: DVF intensity, anatomic site and participating center were significant prognostic factors of DIR performances. Sub-voxel accuracy was obtained in the HN by all algorithms. Large errors, with MDC ranging up to 6 mm, were observed in low-contrast regions that underwent significant deformation, such as in the pelvis, or large DVF with strong contrast, such as the clinical tumor volume (CTV) in the lung. Under these conditions, the hybrid DIR algorithms performed significantly better than the free-form intensity based algorithms and resulted robust against intercenter variability. CONCLUSIONS: The performances of the systems proved to be site specific, depending on the DVF type and the platforms and the procedures used at the various centers. The pelvis was the most challenging site for most of the algorithms, which failed to achieve sub-voxel accuracy. Improved reproducibility was observed among the centers using the same hybrid registration algorithm.

Characterization of phenolic pellets for ESR dosimetry in photon beam radiotherapy.

This work deals with the dosimetric features of a particular phenolic compound (IRGANOX 1076®) for dosimetry of clinical photon beams by using electron spin resonance (ESR) spectroscopy. After the optimization of the ESR readout parameters (namely modulation amplitude and microwave power) to maximise the signal without excessive spectrum distortions, basic dosimetric properties of laboratory-made phenolic dosimeters in pellet form, such as reproducibility, dose-response, sensitivity, linearity and dose rate dependence were investigated. The dosimeters were tested by measuring the depth dose profile of a 6 MV photon beam. A satisfactory intra-batch reproducibility of the ESR signal of the manufactured dosimeters was obtained. The ESR signal proved to increase linearly with increasing dose in the investigated dose range 1-13 Gy. The presence of an intrinsic background signal limits the minimum detectable dose to a value of approximately 0.6 Gy. Reliable and accurate assessment of the dose was achieved, independently of the dose rate. Such characteristics, together with the fact that IRGANOX 1076® is almost tissue-equivalent, and the stability of the ESR signal, make these dosimeters promising materials for ESR dosimetric applications in radiotherapy.

Three-dimensional surface and ultrasound imaging for daily IGRT of prostate cancer.

BACKGROUND: Image guided radiotherapy (IGRT) is an essential pre-requisite for delivering high precision radiotherapy. We compared daily variation detected by two non-ionizing imaging modalities (surface imaging and trans-abdominal ultrasound, US) to verify prostate patient setup and internal organ variations. METHODS: Forty patients with organ confined prostate cancer and candidates to curative radiotherapy were enrolled in this prospective study. At each treatment session, after laser alignment, all patients received imaging by a 3D-surface and a 3D-US system. The shifts along the three directions (anterior-posterior AP, cranial-caudal CC, and later-lateral LL) were measured in terms of systematic and random errors. Then, we performed statistical analysis on the differences and the possible correlations between the two modalities. RESULTS: For both IGRT modalities, surface imaging and US, 1318 acquisitions were collected. According with Shapiro Wilk test, the positioning error distributions were not Gaussian for both modalities. The differences between the systematic errors detected by the two modalities were statistically significant only in LL direction (p < 0.05), while the differences between the random errors were not statistically significant in any directions. The 95% confidence interval of the residual errors obtained by subtracting the random errors detected with surface images to those detected with US was included in the range from -7 mm to 7 mm corresponding to the minimum PTV margin adopted in AP direction in our clinical routine. CONCLUSIONS: From our data, it emerges that setup misalignments measured by surface imaging can be predictive of US displacements after the adjustment for systematic errors. Moreover, surface imaging can detect setup errors predictive of registration errors measured by US. This data suggest that the two IGRT modalities could be considered as complementary to each other and could represent a daily "low-cost" and non-invasive IGRT modality in prostate cancer patients.

Three-dimensional surface imaging for detection of intra-fraction setup variations during radiotherapy of pelvic tumors.

PURPOSE: Surface-based image guided radiotherapy (IGRT) allows positioning and/or monitoring patients in 3 dimensions (3D), without the use of ionizing radiation. In this study, we report on intra-fraction motion measured by acquisition of multiple images of 3D body surfaces. MATERIALS AND METHODS: Twenty-nine patients treated for pelvic tumors were enrolled. Setup variations (SV) through three consecutive body surfaces acquired by the optical IGRT system Align-RT (Vision-RT, London, UK) were analyzed before, during and at the end of treatment delivery. Displacements along the main axes (X, Y and Z) from initial (I) to mid-treatment (MT) and final (F) acquisitions were recorded. Time and direction of SV were assessed. RESULTS: A total of 6272 images from 792 fractions of 29 patients were available. The main source of misalignment was between I and MT acquisition (p < 0.001). The dominant SV direction was the vertical one (Z axis), with mean SV of -1.20 ± 0.06 mm and -1.55 ± 0.06 mm for I-MT and I-F acquisitions, respectively. The Y mean components of SV were, respectively, -0.95 ± 0.10 mm and -1.0 ± 0.10 for I-MT and I-F acquisitions, while the X deviations were 0.07 ± 0.08 mm for I-MT and 0.26 ± 0.08 mm I-F. CONCLUSION: Three-D surface imaging for patient setup monitoring highlighted remarkable mobility of patients during RT session, especially in the anterior-posterior direction (Z axis). The largest magnitude in patient movements occurred during the first part of delivery. These findings suggest that the initial setup control cannot not to be sufficient to guarantee treatment reproducibility, especially for long-lasting RT treatments.

Lung stereotactic ablative body radiotherapy: A large scale multi-institutional planning comparison for interpreting results of multi-institutional studies.

PURPOSE: A large-scale multi-institutional planning comparison on lung cancer SABR is presented with the aim of investigating possible criticism in carrying out retrospective multicentre data analysis from a dosimetric perspective. METHODS: Five CT series were sent to the participants. The dose prescription to PTV was 54Gy in 3 fractions of 18Gy. The plans were compared in terms of PTV-gEUD2 (generalized Equivalent Uniform Dose equivalent to 2Gy), mean dose to PTV, Homogeneity Index (PTV-HI), Conformity Index (PTV-CI) and Gradient Index (PTV-GI). We calculated the maximum dose for each OAR (organ at risk) considered as well as the MLD2 (mean lung dose equivalent to 2Gy). The data were stratified according to expertise and technology. RESULTS: Twenty-six centers equipped with Linacs, 3DCRT (4% - 1 center), static IMRT (8% - 2 centers), VMAT (76% - 20 centers), CyberKnife (4% - 1 center), and Tomotherapy (8% - 2 centers) collaborated. Significant PTV-gEUD2 differences were observed (range: 105-161Gy); mean-PTV dose, PTV-HI, PTV-CI, and PTV-GI were, respectively, 56.8±3.4Gy, 14.2±10.1%, 0.70±0.15, and 4.9±1.9. Significant correlations for PTV-gEUD2 versus PTV-HI, and MLD2 versus PTV-GI, were observed. CONCLUSIONS: The differences in terms of PTV-gEUD2 may suggest the inclusion of PTV-gEUD2 calculation for retrospective data inter-comparison.

Application of failure mode and effects analysis to intracranial stereotactic radiation surgery by linear accelerator.

PURPOSE: The aim of this study was to analyze the application of the failure modes and effects analysis (FMEA) to intracranial stereotactic radiation surgery (SRS) by linear accelerator in order to identify the potential failure modes in the process tree and adopt appropriate safety measures to prevent adverse events (AEs) and near-misses, thus improving the process quality. METHODS AND MATERIALS: A working group was set up to perform FMEA for intracranial SRS in the framework of a quality assurance program. FMEA was performed in 4 consecutive tasks: (1) creation of a visual map of the process; (2) identification of possible failure modes; (3) assignment of a risk probability number (RPN) to each failure mode based on tabulated scores of severity, frequency of occurrence and detectability; and (4) identification of preventive measures to minimize the risk of occurrence. RESULTS: The whole SRS procedure was subdivided into 73 single steps; 116 total possible failure modes were identified and a score of severity, occurrence, and detectability was assigned to each. Based on these scores, RPN was calculated for each failure mode thus obtaining values from 1 to 180. In our analysis, 112/116 (96.6%) RPN values were <60, 2 (1.7%) between 60 and 125 (63, 70), and 2 (1.7%) >125 (135, 180). The 2 highest RPN scores were assigned to the risk of using the wrong collimator's size and incorrect coordinates on the laser target localizer frame. CONCLUSION: Failure modes and effects analysis is a simple and practical proactive tool for systematic analysis of risks in radiation therapy. In our experience of SRS, FMEA led to the adoption of major changes in various steps of the SRS procedure.

Influence of reconstruction settings on the performance of adaptive thresholding algorithms for FDG-PET image segmentation in radiotherapy planning.

The purpose of this study was to analyze the behavior of a contouring algorithm for PET images based on adaptive thresholding depending on lesions size and target-to-background (TB) ratio under different conditions of image reconstruction parameters. Based on this analysis, the image reconstruction scheme able to maximize the goodness of fit of the thresholding algorithm has been selected. A phantom study employing spherical targets was designed to determine slice-specific threshold (TS) levels which produce accurate cross-sectional areas. A wide range of TB ratio was investigated. Multiple regression methods were used to fit the data and to construct algorithms depending both on target cross-sectional area and TB ratio, using various reconstruction schemes employing a wide range of iteration number and amount of postfiltering Gaussian smoothing. Analysis of covariance was used to test the influence of iteration number and smoothing on threshold determination. The degree of convergence of ordered-subset expectation maximization (OSEM) algorithms does not influence TS determination. Among these approaches, the OSEM at two iterations and eight subsets with a 6-8 mm post-reconstruction Gaussian three-dimensional filter provided the best fit with a coefficient of determination R² = 0.90 for cross-sectional areas ≤ 133 mm² and R² = 0.95 for cross-sectional areas > 133 mm². The amount of post-reconstruction smoothing has been directly incorporated in the adaptive thresholding algorithms. The feasibility of the method was tested in two patients with lymph node FDG accumulation and in five patients using the bladder to mimic an anatomical structure of large size and uniform uptake, with satisfactory results. Slice-specific adaptive thresholding algorithms look promising as a reproducible method for delineating PET target volumes with good accuracy.

Influence of different contributions of scatter and attenuation on the threshold values in contrast-based algorithms for volume segmentation.

The aim of this work is to evaluate the role of different amount of attenuation and scatter on FDG-PET image volume segmentation using a contrast-oriented method based on the target-to-background (TB) ratio and target dimensions. A phantom study was designed employing 3 phantom sets, which provided a clinical range of attenuation and scatter conditions, equipped with 6 spheres of different volumes (0.5-26.5 ml). The phantoms were: (1) the Hoffman 3-dimensional brain phantom, (2) a modified International Electro technical Commission (IEC) phantom with an annular ring of water bags of 3 cm thickness fit over the IEC phantom, and (3) a modified IEC phantom with an annular ring of water bags of 9 cm. The phantoms cavities were filled with a solution of FDG at 5.4 kBq/ml activity concentration, and the spheres with activity concentration ratios of about 16, 8, and 4 times the background activity concentration. Images were acquired with a Biograph 16 HI-REZ PET/CT scanner. Thresholds (TS) were determined as a percentage of the maximum intensity in the cross section area of the spheres. To reduce statistical fluctuations a nominal maximum value is calculated as the mean from all voxel > 95%. To find the TS value that yielded an area A best matching the true value, the cross section were auto-contoured in the attenuation corrected slices varying TS in step of 1%, until the area so determined differed by less than 10 mm² versus its known physical value. Multiple regression methods were used to derive an adaptive thresholding algorithm and to test its dependence on different conditions of attenuation and scatter. The errors of scatter and attenuation correction increased with increasing amount of attenuation and scatter in the phantoms. Despite these increasing inaccuracies, PET threshold segmentation algorithms resulted not influenced by the different condition of attenuation and scatter. The test of the hypothesis of coincident regression lines for the three phantoms used provided no statistical basis for believing that the three lines are not coincident. Calibration curves needed to implement contouring algorithms based on adaptive TS segmentation of PET volumes can be devised in different conditions of attenuation and scatter. This opens the possibility of defining a unified contrast-based method for target delineation in different anatomical districts.

Detection of setup uncertainties with 3D surface registration system for conformal radiotherapy of breast cancer.

AIM: To investigate the clinical application of a technique for patient set-up verification in breast cancer radiotherapy based on a 3D surface image registration system. BACKGROUND: Accurate and reproducible patient set-up is a prerequisite to correctly deliver fractionated radiotherapy. Various approaches are available to verify and correct patient setup for 3D image acquisition in a radiation treatment room. MATERIALS AND METHODS: The study analyzed the setup reproducibility of 15 patients affected by breast cancer and candidates for conformal radiotherapy by using the AlignRT system (VisionRT, London, UK). At the initial setup, electronic portal imaging device (EPID) images were compared with Digitally Reconstructed Radiographs (DRRs) and a reference three-dimensional (3D) surface image was obtained by AlignRT. Surface images were acquired prior to every subsequent setup procedure. The systematic and random errors along longitudinal and vertical directions were measured and compared for the two systems. RESULTS: The procedure for surface registration, image acquisition and comparison with the reference image took less than 1 min on average. The T test for systematic error showed no significant difference between the 2 verification systems along the longitudinal (p = 0.69) and vertical (p = 0.67) axes. The T-test for random error showed a significant difference between the 2 systems along the vertical axis (p = 0.05). CONCLUSION: AlignRT is fast, simple, non-invasive and seems to be reliable in detecting patient setup errors. Our results suggest that it could be used to assess the setup reproducibility for breast cancer patients.