Assessment of Radiation-Induced Bladder and Bowel Cancer Risks after Conventionally and Hypo-Fractionated Radiotherapy for the Preoperative Management of Rectal Carcinoma.

Preoperative management of rectal carcinoma can be performed by employing either conventionally or hypo-fractionated Radiotherapy (CFRT or HFRT, respectively), delivered by Intensity Modulated Radiotherapy (IMRT) or Volumetric Modulated Arc Therapy (VMAT) plans, employing 6 MV or 10 MV photon beams. This study aims to dosimetrically and radiobiologically compare all available approaches, with emphasis on the risk of radiation-induced second cancer to the bladder and bowel. Computed Tomography (CT) scans and relevant radiotherapy contours from 16 patients were anonymized and analyzed retrospectively. For each case, CFRT of 25 × 2 Gy and HFRT of 5 × 5 Gy were both considered. IMRT and VMAT plans using 6 MV and 10 MV photons were prepared. Plan optimization was performed, considering all clinically used plan quality indices and dose-volume constraints for the critical organs. Resulting dose distributions were analyzed and compared. Moreover, the Lifetime Attributable Risk (LAR) for developing radiation-induced bladder and bowel malignancies were assessed using a non-linear mechanistic model, assuming patient ages at treatment of 45, 50, 55 and 60 years. All 128 plans created were clinically acceptable. Risk of second bladder cancer reached 0.26% for HFRT (5 × 5 Gy) and 0.19% for CFRT (25 × 2 Gy) at the age of 45. Systematically higher risks were calculated for HFRT (5 × 5 Gy) as compared to CFRT (25 × 2 Gy), with 6 MV photons resulting in slightly increased LAR, as well. Similar or equal bowel cancer risks were calculated for all techniques and patient ages investigated (range 0.05-0.14%). This work contributes towards radiotherapy treatment protocol selection criteria for the preoperative irradiation of rectal carcinoma. However, more studies are needed to establish the associated radiation-induced risk of each RT protocol.

New considerations for colorectal cancer screening based on the demographic profile of colorectal cancer in a Greek population.

Colorectal cancer screening has long been recommended for middle age and older individuals. Recent evidence indicates increasing incidence and mortality among young adults. Therefore, the present study re-examined the current recommendations using an asymptomatic average-risk population screened by colonoscopy. A total of 716 participants of a wide age range were prospectively enrolled in an open-access endoscopic screening program based on self-referral. Comparisons between different age, gender and location groups, and receiver operating characteristic curves (ROC) curves for best age selection for detection of lesions were employed. Increased incidence of advanced lesions was observed in adults <50 years old. Although the polyp size was <1 cm in 85% of the cohort, a significant number of participants harbored advanced lesions. A disturbing incidence of lesions in women 30-49 years was located mainly in the left colon. One-third of the important pathology resides exclusively in the right colon. ROC curves demonstrated that with the current starting age of screening at 50 years, 92% of polyps and 95% of adenomas could be detected by colonoscopy, but a number of potential precancerous lesions will appear at an earlier age and therefore will be missed. The present study supported the notion that it is critical to reduce screening initiation below the currently accepted age of 50 years. Colonoscopy is a suitable method for addressing the increased prevalence of proximal lesions and the meticulous resection of smaller polyps.

Monte Carlo-Based Radiobiological Investigation of the Most Optimal Ion Beam Forming SOBP for Particle Therapy.

Proton (p) and carbon (C) ion beams are in clinical use for cancer treatment, although other particles such as He, Be, and B ions have more recently gained attention. Identification of the most optimal ion beam for radiotherapy is a challenging task involving, among others, radiobiological characterization of a beam, which is depth-, energy-, and cell type- dependent. This study uses the FLUKA and MCDS Monte Carlo codes in order to estimate the relative biological effectiveness (RBE) for several ions of potential clinical interest such as p, 4He, 7Li, 10Be, 10B, and 12C forming a spread-out Bragg peak (SOBP). More specifically, an energy spectrum of the projectiles corresponding to a 5-cm SOBP at a depth of 8 cm was used. All secondary particles produced by the projectiles were considered and RBE was determined based on radiation-induced Double Strand Breaks (DSBs), as calculated by MCDS. In an attempt to identify the most optimal ion beam, using the latter data, biological optimization was performed and the obtained depth-dose distributions were inter-compared. The results showed that 12C ions are more effective inside the SOBP region, which comes at the expense of higher dose values at the tail (i.e., after the SOBP). In contrast, p beams exhibit a higher DSOPB/DEntrance ratio, if physical doses are considered. By performing a biological optimization in order to obtain a homogeneous biological dose (i.e., dose × RBE) in the SOBP, the corresponding advantages of p and 12C ions are moderated. 7Li ions conveniently combine a considerably lower dose tail and a DSOPB/DEntrance ratio similar to 12C. This work contributes towards identification of the most optimal ion beam for cancer therapy. The overall results of this work suggest that 7Li ions are of potential interest, although more studies are needed to demonstrate the relevant advantages. Future work will focus on studying more complex beam configurations.

Evaluation of patient-specific MR distortion correction schemes for improved target localization accuracy in SRS.

PURPOSE: This work aims at promoting target localization accuracy in cranial stereotactic radiosurgery (SRS) applications by focusing on the correction of sequence-dependent (also patient induced) magnetic resonance (MR) distortions at the lesion locations. A phantom-based quality assurance (QA) methodology was developed and implemented for the evaluation of three distortion correction techniques. The same approach was also adapted to cranial MR images used for SRS treatment planning purposes in single or multiple brain metastases cases. METHODS: A three-dimensional (3D)-printed head phantom was filled with a 3D polymer gel dosimeter. Following treatment planning and dose delivery, volumes of radiation-induced polymerization served as hypothetical lesions, offering adequate MR contrast with respect to the surrounding unirradiated areas. T1-weighted (T1w) MR imaging was performed at 1.5 T using the clinical scanning protocol for SRS. Additional images were acquired to implement three distortion correction methods; the field mapping (FM), mean image (MI) and signal integration (SI) techniques. Reference lesion locations were calculated as the averaged centroid positions of each target identified in the forward and reverse read gradient polarity MRI scans. The same techniques and workflows were implemented for the correction of contrast-enhanced T1w MR images of 10 patients with a total of 27 brain metastases. RESULTS: All methods employed in the phantom study diminished spatial distortion. Median and maximum distortion magnitude decreased from 0.7 mm (2.10 ppm) and 0.8 mm (2.36 ppm), respectively, to <0.2 mm (0.61 ppm) at all target locations, using any of the three techniques. Image quality of the corrected images was acceptable, while contrast-to-noise ratio slightly increased. Results of the patient study were in accordance with the findings of the phantom study. Residual distortion in corrected patient images was found to be <0.3 mm in the vast majority of targets. Overall, the MI approach appears to be the most efficient correction method from the three investigated. CONCLUSIONS: In cranial SRS applications, patient-specific distortion correction at the target location(s) is feasible and effective, despite the expense of longer imaging time since additional MRI scan(s) need to be performed. A phantom-based QA methodology was developed and presented to reassure efficient implementation of correction techniques for sequence-dependent spatial distortion.

Apparent diffusion coefficient measurements on a novel diffusion weighted MRI phantom utilizing EPI and HASTE sequences.

PURPOSE: The aim of this study is to introduce a novel DWI-MRI phantom and to compare Apparent Diffusion Coefficient (ADC) measurements, utilizing EPI-DWI and HASTE-DWI sequences and two different fitting algorithms. MATERIALS AND METHODS: 23 test tubes with different sucrose concentrations and polyacrylamide gels were used as a phantom for ADC measurements. The phantom was scanned on a clinical MRI system (1.5 T) over a two-month period utilizing an EPI-DWI and a HASTE-DWI sequence. ADC maps were calculated using a Weighted Linear (WL) and a Non Linear (NL) fitting algorithm. Measurements were performed with two sequences and two fitting algorithms. Geometric Distortions (GD), Ghosting Ratios (GR) and Signal to Structured Noise Ratios (SSNRs) were estimated using both sequences from the resultant ADC parametric maps. RESULTS: Polyacrylamide gels reveal lower coefficient of variation (CV%) as compared to sucrose solutions. ADC measurements performed with WL and NL algorithms reveal identical results with both sequences. WL and NL algorithms require approx. 3 s and 7 min respectively, for a single slice. EPI-DWI reveals a mean percent ADC value difference of (+4.5%) as compared to HASTE-DWI, regardless the type of fitting algorithm. CONCLUSION: Polyacrylamide gels can serve as a better means for simulating ADC values, compared with sucrose solutions used in this study. WL can be proposed as the method for ADC measurements in daily clinical practice. WL is significantly faster than NL fitting method and equally precise. SSNR measured directly on ADC maps is an excellent means for testing the precision of ADC measurements.

Dose perturbation in the radiotherapy of breast cancer patients implanted with the Magna-Site: a Monte Carlo study.

External beam radiation therapy (RT) is often offered to breast cancer patients after surgical mastectomy followed by breast reconstruction with silicone implants. In some cases, the RT is administered while the patient is still implanted with a temporary tissue expander including a high-density metallic port, which is expected to affect the planned dose distribution. This work uses Monte Carlo (MC) simulation in order to evaluate the aforementioned effect when the McGhan Style 133 Tissue Expander with the Magna-Site injection port is used. Simulations have been performed on a patient model built using the actual CT images of the patient for two irradiation schemes, involving two tangential photon beams of 6 MV and 18 MV respectively. MC results show that the presence of the Magna-Site within the two irradiation fields leads to an overall reduction of absorbed dose for points lying in the shadow of the metallic port (relative to each of the opposing beams). The relative reduction compared to dose results without the expander in place ranges from 7% to 13% for the 6 MV beam and is around 6% for the 18 MV photon beam. However, in the close vicinity of the metallic port, increased absorbed doses are observed, due to the increase of secondary electrons emerging from the metallic part of the insert.

A radiobiological investigation on dose and dose rate for permanent implant brachytherapy of breast using 125I or 103Pd sources.

PURPOSE: The present report addresses the question of what could be the appropriate dose and dose rate for 125I and 103PD permanent seed implants for breast cancer as monotherapy for early stage breast cancer. This is addressed by employing a radiobiological methodology, which is based on the linear quadratic model, to identify a biologically effective dose (BED) to the prescription point of the brachytherapy implant, which would produce equivalent cell killing (or same cell survival) when compared to a specified external radiotherapy scheme. METHODS: In the present analysis, the tumor and normal tissue BED ratios of brachytherapy and external radiotherapy are examined for different combinations of tumor proliferation constant (K), alpha/beta ratios, initial dose rate (R0), and reference external radiotherapy scheme (50 or 60 Gy in 2 Gy per fraction). The results of the radiobiological analysis are compared against other reports and clinical protocols in order to examine possible opportunities of improvement. RESULTS: The analysis indicates that physical doses of approximately 100-110 Gy delivered with an initial dose rate of around 0.05 Gyh(-1) and 78-80 Gy delivered at 0.135 Gyh(-1) for 125I and 103Pd permanent implants, respectively, are equivalent to 50 Gy external beam radiotherapy (EBRT) in 2 Gy per fraction. Similarly, for physical doses of approximately 115-127 Gy delivered with an initia dose rate of around 0.059 Gyh(-1) and 92 Gy delivered at 0.157 Gyh(-1) for 125I and 103Pd, respectively, are equivalent to 60 Gy EBRT in 2 Gy per fraction. It is shown that the initial dose rate required to produce isoeffective tumor response with 50 or 60 Gy EBRT in 2 Gy per fraction increases as the repopulation factor K increases, even though repopulation is also considered in EBRT. Also, the initial dose rate increases as the value of the alpha/beta ratio decreases. The impact of the different alpha/beta ratios on the ratio of the tumor BEDs is significantly large for both the 125I and 103Pd implants with the deviation between the alpha/beta = 10.0 Gy ratios and those using the 4.0 and 3.5 Gy values ranging between 18% and 22% in most of the cases. CONCLUSIONS: For the cases of 125I and 103Pd, the equivalent physical doses to 50 Gy EBRT in 2 Gy per fraction are associated with an overdosage of the involved normal tissue in the range of 4%-16% and an underdosage by 10%-15% for a BED for normal tissue, using an alpha/beta value of 3.0 Gy (BEDNT,3 Gy) of 100 Gy. These values are lower by 10%-20% than the published value of 124 Gy for 125I and by about 13% when compared to the published isoeffective dose of 90 Gy for 103Pd. Similarly, the equivalent physical doses to 60 Gy EBRT in 2 Gy per fraction are associated with an overdosage of the involved normal tissue by 10%-20% and an underdosage by 4%-10% for BEDNT,3 Gy of 110 Gy.