Evaluation of the clinical feasibility of cone-beam computed tomography guided online adaption for simulation-free palliative radiotherapy.

Background and purpose: Simulation-free radiotherapy, where diagnostic imaging is used for treatment planning, improves accessibility of radiotherapy for eligible palliative patients. Combining this pathway with online adaptive radiotherapy (oART) may improve accuracy of treatment, expanding the number of eligible patients. This study evaluated the adaptive process duration, plan dose volume histogram (DVH) metrics and geometric accuracy of a commercial cone-beam computed tomography (CBCT)-guided oART system for simulation-free, palliative radiotherapy. Materials and methods: Ten previously treated palliative cases were used to compare system-generated contours against clinician contours in a test environment with Dice Similarity Coefficient (DSC). Twenty simulation-free palliative patients were treated clinically using CBCT-guided oART. Analysis of oART clinical treatment data included; evaluation of the geometric accuracy of system-generated synthetic CT relative to session CBCT anatomy using a Likert scale, comparison of adaptive plan dose distributions to unadapted, using DVH metrics and recording the duration of key steps in the oART workflow. Results: Auto-generated contours achieved a DSC of higher than 0.85, excluding the stomach which was attributed to CBCT image quality issues. Synthetic CT was locally aligned to CBCT anatomy for approximately 80% of fractions, with the remaining suboptimal yet clinically acceptable. Adaptive plans achieved a median CTV V95% of 99.5%, compared to 95.6% for unadapted. The median overall oART process duration was found to be 13.2 mins, with contour editing being the most time-intensive adaptive step. Conclusions: The CBCT-guided oART system utilising a simulation-free planning approach was found to be sufficiently accurate for clinical implementation, this may further streamline and improve care for palliative patients.

Head and Neck Tumor Resection and Free Flap Reconstruction in Low-Volume Center.

OBJECTIVE: To determine the surgical outcomes of free tissue transfer surgery following head and neck tumor extirpation in a low-volume medical center. METHODS: Retrospective chart review of patients who underwent free tissue transfer surgery for head and neck cancer at Moanalua Medical Center from 2015 to 2018. MAIN OUTCOME OF MEASURE: Free flap failure rate and free flap-related complications. RESULTS: From 2015 to 2018, there were 27 free tissue transfer surgery (mean 6.75 flap surgery/year). There were 2 events of partial flap necrosis, and no cases of total flap loss. One patient required leech therapy for venous congestion. One patient required additional free flap surgery. Two patients developed orocutaneous fistula that resolved with local wound care. One patient developed malocclusion following mandible reconstruction using fibular free flap. Overall free flap success rate was 96%. CONCLUSION: This study supports the ability of small-volume centers to produce positive outcomes with few complications in head and neck cancer free flap reconstructive surgery. While the data are limited to a single surgical team in one care center, it provides additional support for the idea that there are factors beyond the surgical volume that determine outcome.

Diagnostic Computed Tomography Enabled Planning for Palliative Radiation Therapy: Removing the Need for a Planning Computed Tomography Scan.

PURPOSE: This study aimed to investigate the feasibility of using diagnostic computed tomography (dCT) for palliative radiation planning, removing the need for a planning computed tomography (pCT) scan. METHODS AND MATERIALS: A sequential 2-stage study was performed. Stage 1 was a retrospective analysis of 150 patients' dCTs and pCTs to review potential barriers to radiation planning, as well as assess the field of view (FOV), patient positioning, couch curvature, and Hounsfield unit (HU) variation, and its dosimetric impact. Stage 2 was a clinical implementation of dCT planning into the clinical care path. Eligible patients were simulated per the standard department protocol in the dCT position. Treatment was planned on the dCT and replicated on the pCT as a backup and comparator. The dCT plan was delivered with cone beam computed tomography (CT) image guidance. After treatment, the delivered plan was recalculated on the modified dCT to compare planned with delivered planning target volume (PTV) dose. RESULTS: Positron emission tomography-CT imaging was the most suited for diagnostic treatment planning. Metastases in the pelvis, abdomen, thoracic, and lumbar spines were the most reproducible. A curved, full-body vac-bag was designed to enable better replication of the posterior body curvature of dCT for treatment. There was minimal variation in mean HU from dCT to pCT scans. Dose difference due to HU variation in the thorax region due to the low-density tissue had the greatest variation. All patients in stage 2 (n = 30) were successfully treated using the dCT plan. Dosimetric evaluations were conducted comparing dCT and modified dCT plans, with the 95% dose coverage change in PTV between -2% to +2.5%. CONCLUSIONS: For palliative patients with bony and soft-tissue metastases, clinically acceptable plans can be produced using dCT. Diagnostic position can be replicated at treatment, eliminating the need for pCT with implications for streamlining and improving care for patients who require palliative radiation therapy.

Introducing Computed Tomography Simulation-Free and Electronic Patient-Reported Outcomes-Monitored Palliative Radiation Therapy into Routine Care: Clinical Outcomes and Implementation Experience.

PURPOSE: Our purpose was to report outcomes of a novel palliative radiation therapy protocol that omits computed tomography simulation and prospectively collects electronic patient-reported outcomes (ePROs). METHODS AND MATERIALS: Patients receiving extracranial, nonstereotactic, linear accelerator-based palliative radiation therapy who met inclusion criteria (no mask-based immobilization and a diagnostic computed tomography within 4 weeks) were eligible. Global pain was scored with the 11-point numerical pain rating scale (NPRS). Patients were coded as having osseous or soft tissue metastases and no/mild versus severe baseline pain (NPRS ≥ 5). Pain response at 4 weeks was measured according to the international consensus (no analgesia adjustment). Transition to ePRO questionnaires was completed in 3 phases. Initially, pain assessments were collected on paper for 11 months, then pilot ePROs for 1 month and then, after adjustments, revised ePROs from 1 year onwards. ePRO feasibility criteria were established with reference to the paper-based process and published evidence. RESULTS: Between May 2018 and November 2019, 542 consecutive patients were screened, of whom 163 were eligible (30%), and 160 patients were successfully treated. The proportion of patients eligible for the study improved from approximately 20% to 50% by study end. Routine care pain monitoring via ePROs was feasible. One hundred twenty-seven patients had a baseline NPRS recording. Ninety-five patients had osseous (61% severe pain) and 32 had soft tissue (25% severe pain) metastases. Eighty-four patients (66%) were assessable for pain response at 4 weeks. In the 41 patients with severe osseous pain, overall and complete pain response was 78% and 22%, respectively. CONCLUSIONS: By study completion, 50% of patients receiving palliative extracranial radiation therapy avoided simulation, streamlining the treatment process and maximizing patient convenience. Pain response for patients with severe pain from osseous lesions was equivalent to published evidence.

Supraclavicular Artery Island Flap in Head and Neck Reconstruction: A Case Series and Literature Review.

INTRODUCTION: Supraclavicular artery island flap (SCAIF) is emerging as an efficient and reliable flap for various complex head and neck defects after tumor extirpation. OBJECTIVE: To examine a series of cases using a SCAIF for head and reconstruction at our institution. METHODS: We performed a retrospective review of 8 patients who underwent SCAIF reconstruction of various head and neck defects from 2015 to 2018 at our institution. We also reviewed the English-language literature of reports of a SCAIF used for head and neck defects. RESULTS: Eight patients underwent SCAIF reconstruction of head and neck defects. Various anatomic sites were reconstructed including the neck (n = 4), oral cavity (n = 1), and parotid/lateral skull base (n = 3). Two patients had partial flap necrosis, requiring débridement and wound care. There was no total loss of the flap or donor-site complication. CONCLUSION: SCAIF is an excellent choice for reconstructing various head and neck defects, with low complication rates and donor-site morbidity. The outcomes of our SCAIF reconstruction are comparable to previously published outcomes.

A Review of the Literature on Native Hawaiian End-of-Life Care: Implications for Research and Practice.

The need for cultural understanding is particularly important in end-of-life (EOL) care planning as the use of EOL care in minority populations is disproportionately lower than those who identify as Caucasian. Data regarding the use of EOL care services by Native Hawaiians in Hawai'i and the United States is limited but expected to be similarly disproportionate as other minorities. In a population with a lower life expectancy and higher prevalence of deaths related to chronic diseases such as cardiovascular disease, diabetes, and obesity, as compared to the state of Hawai'i as a whole, our objective was to review the current literature to understand the usage and perceptions of EOL care planning in the Native Hawaiian population. We searched ten electronic databases and after additional screening, seven articles were relevant to our research purpose. We concluded that limited data exists regarding EOL care use specifically in Native Hawaiians. The available literature highlighted the importance of understanding family and religion influences, educating staff on culturally appropriate EOL care communication, and the need for more research on the topic. The paucity of data in EOL care and decision-making in Native Hawaiians is concerning and it is evident this topic needs more study. From national statistics it looks as though this is another health disparate area that needs to be addressed and is especially relevant when considering the rapid increase in seniors in our population.

Experience with an abdominal compression band for radiotherapy of upper abdominal tumours.

INTRODUCTION: Radiotherapy outcomes are influenced by treatment delivery geometric accuracy and organ-at-risk dose. The location of abdominal structures such as the liver, kidneys and tumour volumes can be strongly influenced by respiratory motion. This increases geometric uncertainty and dose to organs-at-risk. One common method of minimising respiratory motion is abdominal compression (AC). METHODS: Fifteen patients being treated for radiotherapy to upper abdominal tumours were analysed. Each patient underwent 2 four-dimensional computerised tomography (4D-CT) scans, one with and one without AC with a pneumatic compression belt. Liver and kidney positions were measured on the 4DCT scans at the peak inspiratory and expiratory respiratory phases. The patient received radiation therapy treatment planned on the CT data set with the technique (compression or no compression) that provided the least respiratory motion. RESULTS: There was no statistically significant motion difference over the sample population with AC for the kidneys or liver. Of the 14 evaluable patients, 4, 6 and 6 saw reduction in superior-inferior motion for left kidney, right kidney and liver respectively. The remainder either had negligible (<2 mm) or increase in motion with AC. For anterior-posterior motion, 2, 2 and 1 saw a reduction for left-kidney, right-kidney and liver respectively. CONCLUSION: AC through the use of a pneumatic compression belt was found to result in inconsistent reduction in kidney and liver respiratory motion. It is recommended that the effect of AC is evaluated on a per-patient basis.