ACR appropriateness Criteria® Postradical prostatectomy irradiation in prostate cancer.

The purpose of this article is to present an updated set of American College of Radiology consensus guidelines formed from an expert panel on the appropriate use of radiation therapy in postprostatectomy prostate cancer. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. Recent and relevant literature reviewed by the panel led to establishment of criteria for appropriate use of radiation therapy in postprostatectomy prostate cancer. The discussion includes treatment technique, appropriate dose, field design, and the role of prostate-specific antigen (PSA). Ratings and commentary of the panel on multiple treatment parameters were used to reach consensus. Patients with high-risk pathologic features benefit from postprostatectomy radiation therapy.

Relative Incidence of Emergency Department Visits After Treatment for Prostate Cancer With Radiation Therapy or Radical Prostatectomy.

PURPOSE: Side effect profiles play an important role in treatment decisions for localized prostate cancer. Emergency department (ED) visits, which may be due to side effects from treatment, can be measured in real-world, structured, electronic health record (EHR) data. The goal of this study was to determine whether treatments for localized prostate cancer are associated with ED visits, as a measure of side effects, using EHR data. METHODS AND MATERIALS: We used a self-controlled case series study design, including patients treated at an urban academic medical center with radiation therapy (RT) or radical prostatectomy (RP) for prostate cancer between 2011 and 2020 who had visits documented for ≥6 months before and after treatment and ≥1 ED visit. We estimated relative incidences (RI) of ED visits, comparing incidence in the exposed and unexposed periods, with the exposed period being between start of treatment and 1 month after completion, and the unexposed period consisting of all other documented time. RESULTS: Among men who had at least 1 ED visit and after adjusting for age, there were higher rates of ED visits after RP (RI, 20.4; 95% confidence interval [CI], 15.4-27.0; P < .001), RT overall (RI, 2.4; CI, 1.7-3.4; P < .001), intensity modulated radiation therapy with high dose-rate brachytherapy (RI, 3.4; CI, 1.7-6.8; P < .001) or stereotactic body radiation therapy boost (RI, 7.1; CI, 3.4-14.8; P < .001), and high dose rate brachytherapy alone (RI, 16.3; CI, 7.2-36.9; P < .001) compared with unexposed time. The number needed to harm to result in an ED visit was less for RP (17; CI, 13-23) than RT overall (43; CI, 25-126), but varied by RT modality. CONCLUSIONS: In summary, relative rates of ED visits vary by treatment type, suggesting differing severities of side effects. These data may aid in selecting treatments and demonstrate the feasibility of using the self-controlled case series study design on ED visits in real-world, structured EHR data to better understand side effects of treatment.

Endocervical ultrasound applicator for integrated hyperthermia and HDR brachytherapy in the treatment of locally advanced cervical carcinoma.

PURPOSE: The clinical success of hyperthermia adjunct to radiotherapy depends on adequate temperature elevation in the tumor with minimal temperature rise in organs at risk. Existing technologies for thermal treatment of the cervix have limited spatial control or rapid energy falloff. The objective of this work is to develop an endocervical applicator using a linear array of multisectored tubular ultrasound transducers to provide 3-D conformal, locally targeted hyperthermia concomitant to radiotherapy in the uterine cervix. The catheter-based device is integrated within a HDR brachytherapy applicator to facilitate sequential and potentially simultaneous heat and radiation delivery. METHODS: Treatment planning images from 35 patients who underwent HDR brachytherapy for locally advanced cervical cancer were inspected to assess the dimensions of radiation clinical target volumes (CTVs) and gross tumor volumes (GTVs) surrounding the cervix and the proximity of organs at risk. Biothermal simulation was used to identify applicator and catheter material parameters to adequately heat the cervix with minimal thermal dose accumulation in nontargeted structures. A family of ultrasound applicators was fabricated with two to three tubular transducers operating at 6.6-7.4 MHz that are unsectored (360 degrees), bisectored (2 x 180 degrees), or trisectored (3 x 120 degrees) for control of energy deposition in angle and along the device length in order to satisfy anatomical constraints. The device is housed in a 6 mm diameter PET catheter with cooling water flow for endocervical implantation. Devices were characterized by measuring acoustic efficiencies, rotational acoustic intensity distributions, and rotational temperature distributions in phantom. RESULTS: The CTV in HDR brachytherapy plans extends 20.5 +/- 5.0 mm from the endocervical tandem with the rectum and bladder typically <8 mm from the target boundary. The GTV extends 19.4 +/- 7.3 mm from the tandem. Simulations indicate that for 60 min treatments the applicator can heat to 41 degrees C and deliver > 5EM(43 degrees C) over 4-5 cm diameter with Tmax < 45 degrees C and 1 kg m(-3) s(-1) blood perfusion. The 41 degrees C contour diameter is reduced to 3-4 cm at 3 kg m(-3) s(-1) perfusion. Differential power control to transducer elements and sectors demonstrates tailoring of heating along the device length and in angle. Sector cuts are associated with a 14-47 degrees acoustic dead zone, depending on cut width, resulting in a approximately 2-4 degrees C temperature reduction within the dead zone below Tmax. Dead zones can be oriented for thermal protection of the rectum and bladder. Fabricated devices have acoustic efficiencies of 33.4%-51.8% with acoustic output that is well collimated in length, reflects the sectoring strategy, and is strongly correlated with temperature distributions. CONCLUSIONS: A catheter-based ultrasound applicator was developed for endocervical implantation with locally targeted, 3-D conformal thermal delivery to the uterine cervix. Feasibility of heating clinically relevant target volumes was demonstrated with power control along the device length and in angle to treat the cervix with minimal thermal dose delivery to the rectum and bladder.

Risk factors for late bowel and bladder toxicities in NRG Oncology prostate cancer trials of high-risk patients: A meta-analysis of physician-rated toxicities.

PURPOSE: A meta-analysis of sociodemographic variables and their association with late (>180 days from start of radiation therapy[RT]) bowel, bladder, and clustered bowel and bladder toxicities was conducted in patients with high-risk (clinical stages T2c-T4b or Gleason score 8-10 or prostate-specific antigen level >20) prostate cancer. METHODS AND MATERIALS: Three NRG trials (RTOG 9202, RTOG 9413, and RTOG 9406) that accrued from 1992 to 2000 were used. Late toxicities were measured with the Radiation Therapy Oncology Group Late Radiation Morbidity Scale. After controlling for study, age, Karnofsky Performance Status, and year of accrual, sociodemographic variables were added to the model for each outcome variable of interest in a stepwise fashion using the Fine-Gray regression models with an entry criterion of 0.05. RESULTS: A total of 2432 patients were analyzed of whom most were Caucasian (76%), had a KPS score of 90 to 100 (92%), and received whole-pelvic RT+HT (67%). Of these patients, 13 % and 16% experienced late grade ≥2 bowel and bladder toxicities, respectively, and 2% and 3% experienced late grade ≥3 bowel and bladder toxicities, respectively. Late grade ≥2 clustered bowel and bladder toxicities were seen in approximately 1% of patients and late grade ≥3 clustered toxicities were seen in 2 patients (<1%). The multivariate analysis showed that patients who received prostate-only RT+HT had a lower risk of experiencing grade ≥2 bowel toxicities than those who received whole-pelvic RT+long-term (LT) HT (hazard ratio: 0.36; 95% confidence interval, 0.18-0.73; P = .0046 and hazard ratio: 0.43; 95% confidence interval, 0.23-0.80; P = .008, respectively). Patients who received whole-pelvic RT had similar chances of having grade ≥2 bowel or bladder toxicities no matter whether they received LT or short-term HT. CONCLUSIONS: Patients with high-risk prostate cancer who receive whole-pelvic RT+LT HT are more likely to have a grade ≥2 bowel toxicity than those who receive prostate-only RT. LT bowel and bladder toxicities were infrequent. Future studies will need to confirm these findings utilizing current radiation technology and patient-reported outcomes.

Optimization of HDR brachytherapy dose distributions using linear programming with penalty costs.

Prostate cancer is increasingly treated with high-dose-rate (HDR) brachytherapy, a type of radiotherapy in which a radioactive source is guided through catheters temporarily implanted in the prostate. Clinicians must set dwell times for the source inside the catheters so the resulting dose distribution minimizes deviation from dose prescriptions that conform to patient-specific anatomy. The primary contribution of this paper is to take the well-established dwell times optimization problem defined by Inverse Planning by Simulated Annealing (IPSA) developed at UCSF and exactly formulate it as a linear programming (LP) problem. Because LP problems can be solved exactly and deterministically, this formulation provides strong performance guarantees: one can rapidly find the dwell times solution that globally minimizes IPSA's objective function for any patient case and clinical criteria parameters. For a sample of 20 prostates with volume ranging from 23 to 103 cc, the new LP method optimized dwell times in less than 15 s per case on a standard PC. The dwell times solutions currently being obtained clinically using simulated annealing (SA), a probabilistic method, were quantitatively compared to the mathematically optimal solutions obtained using the LP method. The LP method resulted in significantly improved objective function values compared to SA (P = 1.54 x 10(-7)), but none of the dosimetric indices indicated a statistically significant difference (P < 0.01). The results indicate that solutions generated by the current version of IPSA are clinically equivalent to the mathematically optimal solutions.

Registration of MR prostate images with biomechanical modeling and nonlinear parameter estimation.

Magnetic resonance imaging (MRI) and magnetic resonance spectroscopic imaging (MRSI) have been shown to be very useful for identifying prostate cancers. For high sensitivity, the MRI/MRSI examination is often acquired with an endorectal probe that may cause a substantial deformation of the prostate and surrounding soft tissues. Such a probe is removed prior to radiation therapy treatment. To register diagnostic probe-in magnetic resonance (MR) images to therapeutic probe-out MR images for treatment planning, a new deformable image registration method is developed based on biomechanical modeling of soft tissues and estimation of uncertain tissue parameters using nonlinear optimization. Given two-dimensional (2-D) segmented probe-in and probe-out images, a finite element method (FEM) is used to estimate the deformation of the prostate and surrounding tissues due to displacements and forces resulting from the endorectal probe. Since FEM requires tissue stiffness properties and external force values as input, the method estimates uncertain parameters using nonlinear local optimization. The registration method is evaluated using images from five balloon and five rigid endorectal probe patient cases. It requires on average 37 s of computation time on a 1.6 GHz Pentium-M PC. Comparing the prostate outline in deformed probe-out images to corresponding probe-in images, the method obtains a mean Dice Similarity Coefficient (DSC) of 97.5% for the balloon probe cases and 98.1% for the rigid probe cases. The method improves significantly over previous methods (P < 0.05) with greater improvement for balloon probe cases with larger tissue deformations.

3D inverse treatment planning for the tandem and ovoid applicator in cervical cancer.

PURPOSE: Three-dimensional treatment planning systems and inverse planning optimization for brachytherapy are becoming commercially available. Guidelines for target delineation and dose constrictions have not been established using this new software. In this study we describe a method of target delineation for the tandem and ovoids applicator. We then compare inverse planning dose distributions with the traditional methods of prescribing dose. METHODS AND MATERIALS: Target and organ-at-risk volumes were defined using systematic guidelines on 15 patients treated in our department with high-dose-rate brachytherapy for cervical cancer using tandem and ovoids. High-dose-rate distributions were created according to three different dose optimization protocols: inverse planning simulated annealing (IPSA), point A, and point A with a normalization of 2 cc of the bladder receiving 80% of the dose (bladder-sparing method). An uniform cost function for dose constraints was applied to all IPSA generated plans, and no manual optimization was allowed for any planning method. RESULTS: Guidelines for target and structure-at-risk volumes, as well as dose constraint cost functions, were established. Dose-volume histogram analysis showed that the IPSA algorithm indicated no difference in tumor coverage compared with point A optimization while decreasing dose to the bladder and rectum. The IPSA algorithm provided better target volume coverage compared with bladder-sparing method with equivalent doses to the bladder and rectum. CONCLUSION: This study uses a systematic approach for delineating target and organ-at-risk volumes and a uniform cost function for generating IPSA plans for cervical cancer using tandem and ovoids. Compared with conventional dose prescription methods, IPSA provides a consistent method of optimization that maintains or improves target coverage while decreasing dose to normal structures. Image-guided brachytherapy and inverse planning improve brachytherapy dosimetry.

Early clinical experience with anatomy-based inverse planning dose optimization for high-dose-rate boost of the prostate.

PURPOSE: To present an exhaustive dosimetric comparison between three geometric optimization methods and our inverse-planning simulated annealing (IPSA) algorithm, with two different prescriptions for high-dose-rate (HDR) boost of the prostate. The objective of this analysis was to quantify the dosimetric advantages of the IPSA algorithm compared with more standard geometric optimizations. METHODS AND MATERIALS: Between September 1999 and June 2001, 34 patients were treated to a dose of 40-44 Gy by external pelvic fields, followed by an HDR boost of 18 Gy in 3 fractions. The first 4 patients were treated with HDR using geometric optimization, and anatomy-based inverse-planning dose optimization was used for the remaining 30 patients. We retrospectively used the data from these 30 patients to create HDR dose distributions according to five different dose optimization protocols, including our IPSA algorithm. The various geometric optimization procedures differed in the way the dwell positions were activated and plan normalization was performed. Dose-volume histograms from all these plans were analyzed and multiple implant quality indexes extracted. RESULTS: The IPSA algorithm provided better clinical tumor volume prescription dose coverage than did the geometric optimizations. The average prostate volume receiving 100% of the prescribed dose (V100) was 96.3% and 94.5% for IPSA with two different prescriptions compared with 92.1%, 92.6%, and 88.8% for the three geometric optimization schemes. The average urethra V150 value was 0.0% and 0.7% for IPSA with two different prescriptions, and the three geometric optimization protocols generated average values of 22.9%, 33.9%, and 38.8%. The bladder and rectal dose-volume histograms were similar, although the latest version of the IPSA algorithm slightly decreases the dose to these organs at risk because of organ-specific dose constraints included in the objective function. CONCLUSION: We found that planning an HDR prostate boost could be performed in a fast, secure, and effective manner with the IPSA algorithm. We demonstrated that our inverse-planning algorithm produces superior HDR plans than more conventional geometric optimizations for adenocarcinoma of the prostate. The organs at risk protection included in the objective function is a major feature of the algorithm and should allow us to escalate the HDR dose to the prostate without increasing undesirable side effects.

Dose uncertainty due to computed tomography (CT) slice thickness in CT-based high dose rate brachytherapy of the prostate cancer.

In computed tomography (CT)-based high dose rate (HDR) brachytherapy, the uncertainty in the localization of the longitudinal catheter-tip positions due to the discrete CT slice thickness, results in a delivered dose uncertainty. Catheter coordinates were extracted from five patients treated for prostate cancer, and three simulation scenarios were followed to mimic the longitudinal imprecision of the catheter tips, hence the dwell positions. All catheters were displaced (1) forward, (2) backward, or (3) randomly distributed within the space defined by one CT slice thickness, for thicknesses ranging from 2 to 5 mm. Average and standard deviation values of the relative dose variations are reported for the various catheter displacement scenarios. Also, the dose points were grouped according to their relative position in the prostate, inner, peripheral and outer area of prostate and base, median and apex zones, in order to estimate the spatial sensitivity of the dose errors. For scenarios (1) and (2), the dose uncertainties due to the finite slice thickness increase linearly with the slice spacing, from 3% to 8% for the slice thickness values ranging from 2 to 5 mm, respectively. The more realistic scenario (3) yields average errors ranging from 0.7% to 1.7%. The apex and the base show larger dose errors and variability of dose errors than the median of the prostate. No statistical difference was observed among different transversal sections of the prostate. A CT slice thickness of 3 mm appears to be a good compromise showing an acceptable average dose uncertainty of 1%, without unduly increasing the number of slices.

Simulating needle insertion and radioactive seed implantation for prostate brachytherapy.

We are developing a simulation of needle insertion and radioactive seed implantation to facilitate surgeon training and planning for brachytherapy for treating prostate cancer. Inserting a needle into soft tissues causes the tissues to displace and deform: ignoring these effects during seed implantation leads to imprecise seed placements. Surgeons should learn to compensate for these effects so seeds are implanted close to their pre-planned locations. We describe a new 2-D dynamic FEM model based on a 7-phase insertion sequence where the mesh is updated to maintain element boundaries along the needle shaft. The locations of seed implants are predicted as the tissue deforms. The simulation, which achieves 24 frames per second using a 1250 triangular element mesh on a 750Mhz Pentium III PC, is available for surgeon testing by contacting ron@ieor.berkeley.edu.

Pre-plan parameters predict post-implant D90 ≥ 140 Gy for (125)I permanent prostate implants.

PURPOSE: To find permanent prostate implant (PPI) pre-plan dosimetric parameters that predict post-implant D90 ≥ 140 Gy. MATERIAL AND METHODS: Pre-plans were evaluated for 504 patients undergoing PPI with (125)I seeds for low or intermediate risk prostate cancer. Baseline patient and disease factors, numbers of seeds, ratios of number of seeds to available positions (occupancy proportion), and distances between the 100% isodose line and edge of the prostate (margin) planned for the whole prostate (WP), superior (S), inferior (I), anterior (A), and posterior (P) halves, SA, SP, IA, and IP quarters, and superior (ST), inferior (IT), and middle (MT) thirds, and anterior (AT) and posterior (PT) middle one-sixth segments were analyzed by post-implant D90 subset (≥ 140 Gy vs. < 140 Gy). RESULTS: 20% had post-implant D90 < 140 Gy (mean: 128.0 Gy, range: 97.5-139.2) vs. ≥ 140 Gy (mean: 154.4 Gy, range: 140.0-193.5). The D90 ≥ 140 Gy subset had larger AT and IA segment mean numbers of seeds (p = 0.01, 0.046), larger WP, S, A, SA, ST, AT, and MT segment mean margins (p = 0.01, 0.01, 0.001, 0.0001, 0.03, 0.005, 0.02), and lower PT segment occupancy proportion (p = 0.004). On multivariate analysis, independent predictors of post-implant D90 ≥ 140 Gy were increased SA mean margin, no pre-implant 5-α-reductase inhibitor, higher pre-plan D90, decreased P occupancy proportion, no pre-implant hormone therapy, and decreased SP mean margin. CONCLUSIONS: Higher occupancy proportion and larger margins anteriorly and reduced occupancy proportion, and smaller margins posteriorly on PPI pre-plans predict post-implant D90 ≥ 140 Gy.

ACR Appropriateness Criteria high-dose-rate brachytherapy for prostate cancer.

PURPOSE: High-dose-rate (HDR) brachytherapy plays a potential curative role in the treatment of prostate cancer. An expert panel was convened to review the recent literature and reach a consensus on its appropriate clinical applications. METHODS AND MATERIALS: The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. RESULTS: A summary of HDR brachytherapy's clinical applications and recent literature review was completed. Three clinical variants were developed to address common HDR dose, fractionations, and indications for its use in definitive therapy for primary and local recurrent prostate cancer. The panel reached a consensus on the specific treatment approaches with numerical rating and commentary. CONCLUSIONS: In combining available medical literature and expert opinion, this manuscript may serve as an aid for other practitioners in the appropriate application of HDR brachytherapy for prostate cancer.

ACR Appropriateness Criteria® Definitive External-Beam Irradiation in stage T1 and T2 prostate cancer.

PURPOSE: To present the most updated American College of Radiology consensus guidelines formed from an expert panel on the appropriate use of external-beam radiation to manage stage T1 and T2 prostate cancer. METHODS: The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. RESULTS: The panel summarized the most recent and relevant literature on the topic and voted on 3 clinical variants illustrating the appropriate dose, techniques, and use of adjuvant hormone therapy with external-beam radiation for low-risk, intermediate-risk, and high-risk prostate cancer. Numerical rating and commentary reflecting the panel consensus was given for each treatment approach in each variant. CONCLUSIONS: External-beam radiation is a key component of the curative management of T1 and T2 prostate cancer. By combining the most recent medical literature and expert opinion, this guideline can aid clinicians in the appropriate use of external-beam radiation for prostate cancer.

Feasibility of MR imaging/MR spectroscopy-planned focal partial salvage permanent prostate implant (PPI) for localized recurrence after initial PPI for prostate cancer.

PURPOSE: To assess the feasibility of magnetic resonance imaging (MRI)-planned partial salvage permanent prostate implant (psPPI) among patients with biopsy-proven local recurrence after initial PPI without evidence of distant disease. METHODS AND MATERIALS: From 2003-2009, 15 patients underwent MRI/magnetic resonance spectroscopy (MRS) planning for salvage brachytherapy (psPPI, I-125 [n=14; 144 Gy]; Pd-103 [n=1; 125 Gy]) without hormone therapy. Full dose was prescribed to areas of recurrence and underdosage, without entire prostate implantation. Limiting urethral and rectal toxicity was prioritized. Follow-up was from salvage date to prostate-specific antigen (PSA) concentration failure (Phoenix criteria = nadir + 2.0; ASTRO = 3 consecutive rises), recurrence, distant metastases, or last follow-up PSA level. Progression-free survival (PFS) was defined as no PSA failure or biopsy-proven recurrence without all-cause mortality. Toxicity was scored using Common Terminology Criteria for Adverse Events version 4.0. RESULTS: At salvage, median age was 68 years, and PSA concentration was 3.5 ng/mL (range, 0.9-5.6 ng/mL). Abnormal MRI/MRS findings were evident in 40% of patients. Biopsy-proven recurrences consisted of a single focus (80%) or 2 foci (20%). At recurrence, Gleason score was 6 (67%) or ≥7 (27%). Median interval between initial and salvage implantation was 69 months (range, 28-132 months). psPPI planning characteristics limited doses to the rectum (mean V100 = 0.5% [0.07 cc]) and urethra (V100 = 12% [0.3 cc]). At median follow-up (23.3 months; range, 8-88 months), treatment failure (n=2) resulted only in localized recurrence; both patients underwent second psPPI with follow-up PSA tests at 12 and 26 months, resulting in 0.6 and 0.7 ng/mL, respectively. American Society for Radiation Oncology PFS rates at 1, 2, and 3 years were 86.7%, 78.4%, and 62.7%, respectively, with 5 patients for whom treatment failed (n=3 with negative transrectal ultrasound-guided biopsy results). Phoenix PFS rates at 1, 2, and 3 years were 100%, 100%, and 71.4%. 73%, respectively; achieved PSA nadir of <0.5 ng/mL; and 47% of patients had a nadir of <0.1 ng/mL. Treatment-related toxicity was minimal, with no operative interventions, fistulas, or other grade ≥3 gastrointestinal (GI)/genitourinary (GU) toxicity. Thirteen percent had grade 1 GI and 33% had grade 2 GU toxicities. Postsalvage, 20% of patients had no erectile dysfunction, 67% of patients had medication-responsive erectile dysfunction, and 13% of patients had erectile dysfunction refractory to medication. CONCLUSIONS: Focal psPPI with MR-planning in highly selected patients is feasible with short-term control comparable to conventional salvage, with less toxicity. Longer follow-up is needed to confirm its impact on quality of life and treatment.

ACR Appropriateness Criteria® external-beam radiation therapy treatment planning for clinically localized prostate cancer.

Image-based radiation treatment planning and localization have contributed to better targeting of the prostate and sparing of normal tissues. Guidelines are needed to address radiation dose delivery, including patient setup and immobilization, target volume definition, treatment planning, treatment delivery methods, and target localization. Guidelines for external-beam radiation treatment planning have been updated and are presented here. The use of appropriate doses, simulation techniques, and verification of field setup are essential for the accurate delivery of radiation therapy. The ACR Appropriateness Criteria(®) are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Implant strategies for endocervical and interstitial ultrasound hyperthermia adjunct to HDR brachytherapy for the treatment of cervical cancer.

Catheter-based ultrasound devices provide a method to deliver 3D conformable heating integrated with HDR brachytherapy delivery. Theoretical characterization of heating patterns was performed to identify implant strategies for these devices which can best be used to apply hyperthermia to cervical cancer. A constrained optimization-based hyperthermia treatment planning platform was used for the analysis. The proportion of tissue ≥41 °C in a hyperthermia treatment volume was maximized with constraints T(max) ≤ 47 °C, T(rectum) ≤ 41.5 °C, and T(bladder) ≤ 42.5 °C. Hyperthermia treatment was modeled for generalized implant configurations and complex configurations from a database of patients (n = 14) treated with HDR brachytherapy. Various combinations of endocervical (360° or 2 × 180° output; 6 mm OD) and interstitial (180°, 270°, or 360° output; 2.4 mm OD) applicators within catheter locations from brachytherapy implants were modeled, with perfusion constant (1 or 3 kg m(-3) s(-1)) or varying with location or temperature. Device positioning, sectoring, active length and aiming were empirically optimized to maximize thermal coverage. Conformable heating of appreciable volumes (>200 cm(3)) is possible using multiple sectored interstitial and endocervical ultrasound devices. The endocervical device can heat >41 °C to 4.6 cm diameter compared to 3.6 cm for the interstitial. Sectored applicators afford tight control of heating that is robust to perfusion changes in most regularly spaced configurations. T(90) in example patient cases was 40.5-42.7 °C (1.9-39.6 EM(43 °C)) at 1 kg m(-3) s(-1) with 10/14 patients ≥41 °C. Guidelines are presented for positioning of implant catheters during the initial surgery, selection of ultrasound applicator configurations, and tailored power schemes for achieving T(90) ≥ 41 °C in clinically practical implant configurations. Catheter-based ultrasound devices, when adhering to the guidelines, show potential to generate conformal therapeutic heating ranging from a single endocervical device targeting small volumes local to the cervix (<2 cm radial) to a combination of a 2 × 180° endocervical and directional interstitial applicators in the lateral periphery to target much larger volumes (6 cm radial), while preferentially limiting heating of the bladder and rectum.

ACR Appropriateness Criteria® definitive external beam irradiation in stage T1 and T2 prostate cancer.

PURPOSE: : External beam radiation therapy is a standard of care treatment for men who present with clinically localized (T1-T2) prostate cancer. The purpose of this review was to provide clarification on the appropriateness criteria and management considerations for the treatment of prostate cancer with external beam radiation therapy. METHODS: : A panel consisting of physicians with expertise on prostate cancer was assembled and provided with a number of clinical scenarios for consensus treatment and management guidelines. Prostate cancer patient vignettes were presented along with specific management recommendations based on an extensive review of the modern external beam radiotherapy literature. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances, where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. RESULTS: : Modern external beam radiation therapy series demonstrate favorable biochemical control rates for patients with localized prostate cancer. Morbidity profiles are also favorable and it is clear that this is enhanced by modern techniques like 3-dimensional conformal radiation therapy and intensity-modulated radiation therapy. An active area of investigation is evaluating the use of hypofractionated dosing. CONCLUSIONS: : Continued investigation to refine patient selection, external beam radiation technology application, and alternative dosing schedules should result in further improvements in biochemical outcome and decreased morbidity with external beam radiation treatment for localized prostate cancer.

American College of Radiology Appropriateness Criteria permanent source brachytherapy for prostate cancer.

PURPOSE: Permanent prostate brachytherapy has emerged as a standard of care treatment for approximately 50,000 men annually who present with clinically localized prostate cancer. The purpose of this review was to provide clarification on the appropriateness criteria and management considerations for the treatment of prostate cancer with permanent prostate brachytherapy. METHODS: Panel members with expertise on prostate cancer were assembled and provided several clinical scenarios for consensus treatment and management guidelines. Prostate cancer patient vignettes were presented along with specific management recommendations based on an extensive review of the modern brachytherapy literature. The brachytherapy topic development and review consists of two parts which require extensive participation by the expert panel. The American College of Radiology (ACR) Appropriateness Criteria (AC) are derived from a multidisciplinary panel of experts from both the academic and private practice settings. The first activity is a review of the current literature with development of an evidence table, referenced narrative, and ratings table of treatments. The second activity is the consensus-building process using a modified Delphi technique via an anonymous voting process. RESULTS: Most brachytherapy series have demonstrated favorable morbidity profiles and durable biochemical control rates for patients with low-, intermediate-, and high-risk features. However, as brachytherapy followups have matured, it has become increasingly apparent that efficacy and morbidity are highly dependent on implant quality. CONCLUSION: Continued attempts to refine patient selection, brachytherapy treatment planning philosophy, technique, and postimplant management should result in further improvements in biochemical outcome and decreased brachytherapy-related morbidity.

Sensorless motion planning for medical needle insertion in deformable tissues.

Minimally invasive medical procedures such as biopsies, anesthesia drug injections, and brachytherapy cancer treatments require inserting a needle to a specific target inside soft tissues. This is difficult because needle insertion displaces and deforms the surrounding soft tissues causing the target to move during the procedure. To facilitate physician training and preoperative planning for these procedures, we develop a needle insertion motion planning system based on an interactive simulation of needle insertion in deformable tissues and numerical optimization to reduce placement error. We describe a 2-D physically based, dynamic simulation of needle insertion that uses a finite-element model of deformable soft tissues and models needle cutting and frictional forces along the needle shaft. The simulation offers guarantees on simulation stability for mesh modifications and achieves interactive, real-time performance on a standard PC. Using texture mapping, the simulation provides visualization comparable to ultrasound images that the physician would see during the procedure. We use the simulation as a component of a sensorless planning algorithm that uses numerical optimization to compute needle insertion offsets that compensate for tissue deformations. We apply the method to radioactive seed implantation during permanent seed prostate brachytherapy to minimize seed placement error.