Unravelling Quality of Life for Head and Neck Cancer Patients after VMAT Radiation Therapy: Insights from Toxicity, Dosimetry and Symptoms Correlation.

(1) Background: Head and neck cancer treatment, including advanced techniques like Volumetric Modulated Arc Therapy (VMAT), presents challenges for maintaining patient quality of life (QoL). Thus, thoroughly investigating how radiation therapy (RT) affects patients has been proved essential. Derived by that, this study aims to understand the complex interactions between not only RT and QoL but also symptom severity, and treatment-related toxicities in three distinct time points of patient's treatment; (2) Methods: To achieve that, EORTC-QLQ-C30 and EORTC QLQ-H&N35 questionnaires were used in combination with EORTC_RTOG scoring criteria and Spearman's rho statistical analysis for 74 patients with cancer undergoing VMAT radiation therapy; (3) Results: The results revealed a significant improvement in the Overall Health Index post-treatment, indicating a temporary decline during therapy followed by subsequent recovery, often surpassing pre-treatment QoL levels. Concurrently a reduction in symptomatology was observed, notably in pain, swallowing difficulties, and dry mouth, aligning with prior research indicating decreased symptom burden post-treatment. However, Spearman's correlation coefficient analysis at two distinct time points during therapy uncovered varying degrees of correlation between dosimetric data at Organs at Risk (OARs) and reported symptoms, highlighting potential limitations in using QoL questionnaires as sole indicators of treatment efficacy. Our investigation into the correlation between dosimetric data, toxicity, and symptoms focused on the relationship between radiation doses and oral mucositis levels, a common toxicity in head and neck cancer patients. Significant associations were identified between toxicity levels and dosimetric parameters, particularly with OARs such as the parotid glands, oral cavity, and swallowing muscles, underlining the utility of the EORTC method as a reliable toxicity assessment tool; (4) Conclusions: To summarize, current research attempts to underscore the importance of refining QoL assessments for enhanced patient care. The integration of dosimetric data, symptom severity, and treatment-related toxicities in the QoL outcomes of head and neck cancer patients undergoing VMAT radiation therapy, can lead towards the optimization of treatment strategies and the improvement of patient outcomes in future patient-centered radiation therapy practices.

Single- versus Multi-computed Tomography Simulation for High-dose-rate Postoperative Gynecological Intracavitary Brachytherapy.

Introduction: This study aimed to investigate whether there is a dosimetric difference of implementing single instead of multi-computed tomography (CT) simulation treatment planning for high-dose-rate postoperative gynecological intracavitary brachytherapy (BT). Materials and Methods: Eighty patients were registered in the study. They received three BT fractions of 7 Gy/week (three CTs, three original plans). The organs at risk (OAR), the rectal wall, and the clinical target volume (CTV) were delineated. The delivered doses for the 2cc of OARs (D2cc), 1cc of rectal wall (D1cc), as well as for the 90% and 100% of CTV volume (DCTV90%, DCTV100%) were evaluated. To evaluate the values of the above parameters if the single-CT-simulation method has been chosen, the time of the first treatment plan was corrected for the decay and applied as the second and third CT, retrospectively, creating the next fractions (two revised plans). Results: No statistically significant (P > 0.05) differences were found between the original and revised plans for the OARs and CTV. However, for the single-CT-simulation method, it was noted that the dose constraints for the total rectal dose were exceeded in some cases (36.3%). Conclusion: The fact that rectal dose constraints were exceeded in 1/3 of patients with the single-CT-simulation method is dosimetrically significant.

Comprehensive 3DCRT Hypofractionated Radiotherapy Schedule for Localized Prostate Adenocarcinoma in the Era of IMRT: Dosimetric and Endoscopic Analysis.

Background: Moderate hypofractionated radiotherapy (MHRT) has emerged as the preferred treatment modality for localized prostate cancer based on randomized controlled studies regarding efficacy and toxicity using contemporary radiotherapy techniques. In the setting of MHRT, available data on dosimetric parameters and late rectal toxicity are limited. Aim: To present the effects of MHRT on late rectal toxicity while conducting an extensive dosimetric analysis in conjunction with rectoscopy results. Methods: This is a prospective study including patients with intermediate-risk prostate adenocarcinoma. All patients were treated with MHRT 44 Gy in 16 fractions to the seminal vesicles and to the prostate, followed by a sequential boost to the prostate alone of 16.5 Gy in 6 fractions delivered with three-dimensional conformal radiation therapy (3DCRT). Acute and late toxicity were assessed. Endoscopy was performed at baseline, every 3 months post-therapy for the first year, and every 6 months for the year after. The Vienna Rectoscopy Score (VRS) was used to assess rectal mucosal injury related to radiotherapy. Dosimetric analysis for the rectum, rectal wall, and its subsegments (upper, mid, and low 1/3) was performed. Results: Between September 2015 and December 2019, 20 patients enrolled. Grade 1 late gastrointestinal toxicity occurred in 10% of the patients, whereas 5% had a grade ≥2. Twelve months post radiotherapy: 4 (20%) patients had VRS 1; 2 (10%) patients had VRS 2; 1(5%) patient had VRS 3. 24 months post radiotherapy, VRS 1 was observed in 4 patients (20%) and VRS 2 in 3 (15%) patients. The dosimetric analysis demonstrated noticeable variations between the rectum, rectal wall, and rectal wall subsegments. The dosimetric analysis of the rectum, rectal wall, and its mid and low segments with respect to rectoscopy findings showed that the higher dose endpoints V52.17Gy and V56.52Gy are associated with rectal mucosal injury. Conclusions: A thorough delineation of the rectal wall and its subsegments, together with the dosimetric analysis of these structures, may reduce late rectal toxicity. Dosimetric parameters such as V52.17Gy and V56.52Gy were identified to have a significant impact on rectal mucosal injury; additional dose endpoint validation and its relation to late GI toxicity is needed.

The Impact of Nanomedicine on Soft Tissue Sarcoma Treated by Radiotherapy and/or Hyperthermia: A Review.

This article presents a comprehensive review of nanoparticle-assisted treatment approaches for soft tissue sarcoma (STS). STS, a heterogeneous group of mesenchymal-origin tumors with aggressive behavior and low overall survival rates, necessitates the exploration of innovative therapeutic interventions. In contrast to conventional treatments like surgery, radiotherapy (RT), hyperthermia (HT), and chemotherapy, nanomedicine offers promising advancements in STS management. This review focuses on recent research in nanoparticle applications, including their role in enhancing RT and HT efficacy through improved drug delivery systems, novel radiosensitizers, and imaging agents. Reviewing the current state of nanoparticle-assisted therapies, this paper sheds light on their potential to revolutionize soft tissue sarcoma treatment and improve patient therapy outcomes.

Nanoparticle-Mediated Radiotherapy: Unraveling Dose Enhancement and Apoptotic Responses in Cancer and Normal Cell Lines.

Cervical cancer remains a pressing global health concern, necessitating advanced therapeutic strategies. Radiotherapy, a fundamental treatment modality, has faced challenges such as targeted dose deposition and radiation exposure to healthy tissues, limiting optimal outcomes. To address these hurdles, nanomaterials, specifically gold nanoparticles (AuNPs), have emerged as a promising avenue. This study delves into the realm of cervical cancer radiotherapy through the meticulous exploration of AuNPs' impact. Utilizing ex vivo experiments involving cell lines, this research dissected intricate radiobiological interactions. Detailed scrutiny of cell survival curves, dose enhancement factors (DEFs), and apoptosis in both cancer and normal cervical cells revealed profound insights. The outcomes showcased the substantial enhancement of radiation responses in cancer cells following AuNP treatment, resulting in heightened cell death and apoptotic levels. Significantly, the most pronounced effects were observed 24 h post-irradiation, emphasizing the pivotal role of timing in AuNPs' efficacy. Importantly, AuNPs exhibited targeted precision, selectively impacting cancer cells while preserving normal cells. This study illuminates the potential of AuNPs as potent radiosensitizers in cervical cancer therapy, offering a tailored and efficient approach. Through meticulous ex vivo experimentation, this research expands our comprehension of the complex dynamics between AuNPs and cells, laying the foundation for their optimized clinical utilization.

Isodose surface differences: A novel tool for the comparison of dose distributions.

BACKGROUND: Comparing dose distributions is a routine task in radiotherapy, mainly in patient-specific quality assurance (PSQA). Currently, the evaluation of the dose distributions is being performed mainly with statistical methods, which could underestimate the clinical importance of the spotted differences, as per the literature. PURPOSE: This paper aims to provide proof-of-concept for a novel dose distribution comparison method based on the difference of the isodose surfaces. The new method connects acceptance tolerance to QA limitations (equipment capabilities) and integrates a clinical approach into the analysis procedure. METHODS: The distance of dose points from the isocenter can be used as a function to define the shape of an isodose surface expressed as a histogram. Isodose surface differences (ISD) are defined as the normalized differences of reference and evaluated surface histograms plotted against their corresponding isodose. Acceptance tolerances originate from actual QA tolerances and are presented clinically intuitively. The ISD method was compared to the gamma index using intentionally erroneous VMAT and IMRT plans. RESULTS: Results revealed that the ISD method is sensitive to all errors induced in the plans. Discrepancies are presented per isodose, enabling the evaluation of the plan in two regions representing PTV and Normal Tissue. ISD manages to flag errors that would remain undetected under the gamma analysis. CONCLUSION: The ISD method is a meaningful, QA-related, registration-free, and clinically oriented technique of dose distribution evaluation. This method can be used either as a standalone or an auxiliary tool to the well-established evaluation procedures, overcoming significant limitations reported in the literature.

Prostate Cancer Stem Cells: Biology and Treatment Implications.

Stem cells differentiate into mature organ/tissue-specific cells at a steady pace under normal conditions, but their growth can be accelerated during the process of tissue healing or in the context of certain diseases. It is postulated that the proliferation and growth of carcinomas are sustained by the presence of a vital cellular compartment resembling stem cells residing in normal tissues: 'stem-like cancer cells' or cancer stem cells (CSCs). Mutations in prostate stem cells can lead to the formation of prostate cancer. Prostate CSCs (PCSCs) have been identified and partially characterized. These express surface markers include CD44, CD133, integrin α2ß1, and pluripotency factors like OCT4, NANOG, and SOX2. Several signaling pathways are also over-activated, including Notch, PTEN/Akt/PI3K, RAS-RAF-MEK-ERK and HH. Moreover, PCSCs appear to induce resistance to radiotherapy and chemotherapy, while their presence has been linked to aggressive cancer behavior and higher relapse rates. The development of treatment policies to target PCSCs in tumors is appealing as radiotherapy and chemotherapy, through cancer cell killing, trigger tumor repopulation via activated stem cells. Thus, blocking this reactive stem cell mobilization may facilitate a positive outcome through cytotoxic treatment.

Surface-Guided Radiotherapy: Can We Move on from the Era of Three-Point Markers to the New Era of Thousands of Points?

The surface-guided radiotherapy (SGRT) technique improves patient positioning with submillimeter accuracy compared with the conventional positioning technique of lasers using three-point tattoos. SGRT provides solutions to considerations that arise from the conventional setup technique, such as variability in tattoo position and the psychological impact of the tattoos. Moreover, SGRT provides monitoring of intrafractional motion. PURPOSE: This literature review covers the basics of SGRT systems and examines whether SGRT can replace the traditional positioning technique. In addition, it investigates SGRT's potential in reducing positioning times, factors affecting SGRT accuracy, the effectiveness of live monitoring, and the impact on patient dosage. MATERIALS AND METHODS: This study focused on papers published from 2016 onward that compared SGRT with the traditional positioning technique and investigated factors affecting SGRT accuracy and effectiveness. RESULTS/CONCLUSIONS: SGRT provides the same or better results regarding patient positioning. The implementation of SGRT can reduce overall treatment time. It is an effective technique for detecting intrafraction patient motion, improving treatment accuracy and precision, and creating a safe and comfortable environment for the patient during treatment.

Dosimetric comparison and evaluation of two computational algorithms in VMAT treatment plans.

PURPOSE: This study aimed to assess the accuracy and dosimetric impact of the Acuros XB (AXB) algorithm compared to the Anisotropic Analytical Algorithm (AAA) in two situations. First, simple phantom geometries were set and analyzed; moreover, volumetric modulated arc therapy (VMAT) clinical plans for Head & Neck and lung cases were calculated and compared. METHODS: First, a phantom study was performed to compare the algorithms with radiochromic EBT3 film doses using one PMMA slab phantom and two others containing foam or air gap. Subsequently, a clinical study was conducted, including 20 Head & Neck and 15 lung cases irradiated with the VMAT technique. The treatment plans calculated by AXB and AAA were evaluated in terms of planning target volume (PTV) coverage (V95% ), dose received by relevant organs at risk (OARs), and the impact of using AXB with a grid size of 1 mm. Finally, patient-specific quality assurance (PSQA) was performed and compared for 17 treatment plans. RESULTS: Phantom dose calculations showed a better agreement of AXB with the film measurements. In the clinical study, AXB plans exhibited lower Conformity Index and PTV V95% , higher maximum PTV dose, and lower mean and minimum PTV doses for all anatomical sites. The most notable differences were detected in regions of intense heterogeneity. AXB predicted lower doses for the OARs, while the calculation time with a grid size of 1 mm was remarkably higher. Regarding PSQA, although AAA was found to exhibit slightly higher gamma passing rates, the difference did not affect the AXB treatment plan quality. CONCLUSIONS: AXB demonstrated higher accuracy than AAA in dose calculations of both phantom and clinical conditions, specifically in interface regions, making it suitable for sites with large heterogeneities. Hence, such dosimetric differences between the two algorithms should always be considered in clinical practice.

EFOMP Malaga Declaration 2023: An updated vision on Medical Physics in Europe.

In 2006, the European Federation of Organisations for Medical Physics (EFOMP) adopted the "Malaga Declaration". The declaration asserted the fundamental role of Medical Physics professionals in the radiation protection of patients, workers, general public, carers and comforters and research participants in hospitals. However, since that time the Medical Physics profession has evolved in Europe and new regulations and documentation have been issued, such as directive 2013/59/Euratom and the "European Guidelines on Medical Physics Expert" (RP174). EFOMP has published updated core-curricula and strived towards the recognition of the profession at the European level. In view of this, an update of the original Malaga Declaration was deemed necessary, to define the future vision that will guide the actions of the Federation in the years to come. This Declaration, which has been approved by the national member organizations of EFOMP in April 2023, is much broader than the original Malaga version. This is expected considering the rapid evolution of medical device technology over the last 17 years. The Radiation Protection Expert in hospital settings should be an MPE, since the latter has the highest level of radiation protection knowledge and training. Given the passion and energy that animated the debate, which led to the updating of the Malaga Declaration, we are confident that it represents a solid basis for the development of our profession in Europe which is in consonance with the aspirations of us all.

Immune Response and Immune Checkpoint Molecules in Patients with Rectal Cancer Undergoing Neoadjuvant Chemoradiotherapy: A Review.

It is well-established that tumor antigens and molecules expressed and secreted by cancer cells trigger innate and adaptive immune responses. These two types of anti-tumor immunity lead to the infiltration of the tumor's microenvironment by immune cells with either regulatory or cytotoxic properties. Whether this response is associated with tumor eradication after radiotherapy and chemotherapy or regrowth has been a matter of extensive research through the years, mainly focusing on tumor-infiltrating lymphocytes and monocytes and their subtypes, and the expression of immune checkpoint and other immune-related molecules by both immune and cancer cells in the tumor microenvironment. A literature search has been conducted on studies dealing with the immune response in patients with rectal cancer treated with neoadjuvant radiotherapy or chemoradiotherapy, assessing its impact on locoregional control and survival and underlying the potential role of immunotherapy in the treatment of this cancer subtype. Here, we provide an overview of the interactions between local/systemic anti-tumor immunity, cancer-related immune checkpoint, and other immunological pathways and radiotherapy, and how these affect the prognosis of rectal cancer patients. Chemoradiotherapy induces critical immunological changes in the tumor microenvironment and cancer cells that can be exploited for therapeutic interventions in rectal cancer.

Implementation, Dosimetric Assessment, and Treatment Validation of Knowledge-Based Planning (KBP) Models in VMAT Head and Neck Radiation Oncology.

The aim of this study was to evaluate knowledge-based treatment planning (KBP) models in terms of their dosimetry and deliverability and to investigate their clinical benefits. Three H&N KBP models were built utilizing RapidPlan™, based on the dose prescription, which is given according to the planning target volume (PTV). The training set for each model consisted of 43 clinically acceptable volumetric modulated arc therapy (VMAT) plans. Model quality was assessed and compared to the delivered treatment plans using the homogeneity index (HI), conformity index (CI), structure dose difference (PTV, organ at risk-OAR), monitor units, MU factor, and complexity index. Model deliverability was assessed through a patient-specific quality assurance (PSQA) gamma index-based analysis. The dosimetric assessment showed better OAR sparing for the RapidPlan™ plans and for the low- and high-risk PTV, and the HI, and CI were comparable between the clinical and RapidPlan™ plans, while for the intermediate-risk PTV, CI was better for clinical plans. The 2D gamma passing rates for RapidPlan™ plans were similar or better than the clinical ones using the 3%/3 mm gamma-index criterion. Monitor units, the MU factors, and complexity indices were found to be comparable between RapidPlan™ and the clinical plans. Knowledge-based treatment plans can be safely adapted into clinical routines, providing improved plan quality in a time efficient way while minimizing user variability.

A step closer to automation: kilovoltage and Megavoltage Planar Imaging Quality Assurance, baseline, tolerance and action levels definition and exploration.

PURPOSE: To establish automated quality assurance (QA) procedures for the kilovoltage (kV) and the Megavoltage (MV) imagers of two linear accelerators (LINACS) using a commercial software. METHODS: SNC Machine™ phantoms and software were used and the baseline values, tolerance and action levels for various image quality parameters were defined. Scaling, spatial resolution, contrast, uniformity and noise were considered, explored and evaluated utilizing the appropriate phantoms and the accompanying software. kV and MV planar radiographic images, for 6MV and 10MV beams were obtained for each LINAC. For both kV and MV QA tasks, the baseline values for spatial resolution, contrast, uniformity and noise were defined. RESULTS: Subsequent measurements performed were highly reproducible and within tolerance and action levels, while noise showed variations. The calculated tolerance and action levels for noise were looser compared to the other image quality metrics. CONCLUSIONS: An automated QA workflow of the kV and MV planar radiographic mode of LINAC imagers' was established and appears to be time effective.

Craniospinal Irradiation: A Dosimetric Comparison Between O-Ring Linac and Conventional C-arm Linac.

Purpose: The aim of this study was to perform a dosimetric evaluation between craniospinal irradiation volumetric modulated arc therapy plans designed for an O-Ring and a conventional C-arm Linac. Methods and Materials: Two adult patients were selected for this study. Two plans were designed one for a TrueBeam Edge and one for Halcyon O-ring Linac for each patient. The evaluation of the plans was conducted in terms of dose volume histogram analysis of the target volume and organs at risk (OARs) along with total plan monitor units and beam-on time. Paired sample t test was performed to compare Dmax and Dmean of OARs for each plan's comparison. The delivery of volumetric modulated arc therapy plans was evaluated using Octavius 4D phantom. Results: All plans demonstrated dose distributions with sufficient planned target volume conformity and homogeneity. The Homogeneity Index and Conformity Index for all plans were found comparable. The paired sample t test did not demonstrate significant difference in terms of Dmax and Dmean of OARs between plans for both patients. All plans met the threshold of 90%, with Halcyon plans having higher gamma passing rates. Conclusions: Craniospinal irradiation plans generated for Halcyon and Edge are equivalent in terms of plan quality and dose sparing at OARs. The small variations may have originated from the differences in beam profile or mean energy, the degree of the modulation for each plan and characteristics of multi leaf collimators for each treatment unit. Halcyon is able to deliver a distinctly faster treatment, but Edge provides an automatic rotational correction for patient positioning.

Synchronous bilateral chest wall irradiation with regional nodal irradiation: A literature review of techniques and a case study.

The optimal radiotherapy technique for patients requiring both breasts or chest walls simultaneous irradiation with or without regional nodal irradiation is currently under investigation. In the last decade several publications present case reports and case series of patients treated with adjuvant radiotherapy in both breasts or chest walls for synchronous bilateral breast cancer (SBBC) with modern radiotherapy techniques. This article presents a systematic review of relevant literature as well as a case report of a SBBC patient who received bilateral chest wall radiotherapy with regional nodal irradiation at our institution with Truebeam - Edge Linear Accelerator. Solid evidence is provided that the practice of avoiding adjuvant radiotherapy in SBBC out of fear of toxicity with older radiotherapy techniques is outdated. Modern techniques can safely and effectively deliver treatment to patients requiring both sides irradiation and even in mastectomy patients in need of regional nodal irradiation.

Early Prediction of Planning Adaptation Requirement Indication Due to Volumetric Alterations in Head and Neck Cancer Radiotherapy: A Machine Learning Approach.

BACKGROUND: During RT cycles, the tumor response pattern could affect tumor coverage and may lead to organs at risk of overdose. As such, early prediction of significant volumetric changes could therefore reduce potential radiation-related adverse effects. Nevertheless, effective machine learning approaches based on the radiomic features of the clinically used CBCT images to determine the tumor volume variations due to RT not having been implemented so far. METHODS: CBCT images from 40 HN cancer patients were collected weekly during RT treatment. From the obtained images, the Clinical Target Volume (CTV) and Parotid Glands (PG) regions of interest were utilized to calculate 104 delta-radiomics features. These features were fed on a feature selection and classification procedure for the early prediction of significant volumetric alterations. RESULTS: The proposed framework was able to achieve 0.90 classification performance accuracy while detecting a small subset of discriminative characteristics from the 1st week of RT. The selected features were further analyzed regarding their effects on temporal changes in anatomy and tumor response modeling. CONCLUSION: The use of machine learning algorithms offers promising perspectives for fast and reliable early prediction of large volumetric deviations as a result of RT treatment, exploiting hidden patterns in the overall anatomical characteristics.

Quantification of Nanoscale Dose Enhancement in Gold Nanoparticle-Aided External Photon Beam Radiotherapy.

The recent progress in Nanotechnology has introduced Gold Nanoparticles (AuNPs) as promising radiosensitizing agents in radiation oncology. This work aims to estimate dose enhancement due to the presence of AuNPs inside an irradiated water region through Monte Carlo calculations. The GATE platform was used to simulate 6 MV photon histories generated from a TrueBeam® linear accelerator with and without a Flattening Filter (FF) and model AuNPs clusters. The AuNPs size, concentration and distribution pattern were examined. To investigate different clinical irradiation conditions, the effect of field size, presence of FF and placement of AuNPs in water were evaluated. The range of Dose Enhancement Factors (DEF = DoseAu/DoseWater) calculated in this study is 0.99 ± 0.01-1.26 ± 0.02 depending on photon beam quality, distance from AuNPs surface, AuNPs size and concentration and pattern of distribution. The highest DEF is reported for irradiation using un-flattened photon beams and at close distances from AuNPs. The obtained findings suggest that dose deposition could be increased in regions that represent whole cells or subcellular targets (mitochondria, cell nucleus, etc.). Nevertheless, further and consistent research is needed in order to make a step toward AuNP-aided radiotherapy in clinical practice.

Implementation of TG-218 for patient-specific quality assurance tolerance and action limits determination: Gamma passing rate evaluation using 3DVH software.

PURPOSE: To determine the tolerance limit (TL) and action limit (AL) of gamma passing rates (%GP) for volumetric-modulated arc therapy (VMAT) patient-specific quality assurance (PSQA) according to the American Association of Physicists in Medicine (AAPM) Task Group (TG)-218 recommendations, and to comparatively evaluate the clinical relevance of 2D %GP and 3D %GP. METHODS: PSQA was performed for 100 head and neck (H&N) and 73 prostate cancer VMAT treatment plans. Measurements were acquired using a cylindrical water equivalent phantom, hollow in the center, allowing measurements with homogeneous or heterogeneous inserts. The LINAC-delivered dose distributions were compared to those calculated from the treatment planning system through the gamma index. TL and AL were determined through the computation of two-dimensional (2D) %GP using the recommended acceptance criteria. Dose-volume histograms were reconstructed from the measurements using a commercially available software to detect the dosimetric errors (%DE) between the compared dose distributions. Utilizing the estimated dose on the patient anatomy, structure-specific %GP (3D %GP) were calculated. The 3D %GP were compared to the 2D %GP ones based on their correlation with the %DE. Each metric's sensitivity was determined through receiver operator characteristic analysis. RESULTS: TL and AL were in concordance with the universal ones, regarding the prostate cancer cases, but were lower for the H&N cases. Evaluation of %DE did not deem the plans unacceptable. The 2D %GP and the 3D %GP did not differ significantly regarding their correlation with %DE. For prostate plans, %GP sensitivity was higher than for H&N cases. CONCLUSIONS: Determination of institutional-specific TL and AL allows the monitoring of the PSQA procedure, yet for plans close to the limits, clinically relevant metrics should be used before they are deemed unacceptable for the process to be of higher sensitivity and efficiency.

The Role of Ionizing Radiation for Diagnosis and Treatment against COVID-19: Evidence and Considerations.

The Coronavirus disease 2019 (COVID-19) pandemic continues to spread worldwide with over 260 million people infected and more than 5 million deaths, numbers that are escalating on a daily basis. Frontline health workers and scientists diligently fight to alleviate life-threatening symptoms and control the spread of the disease. There is an urgent need for better triage of patients, especially in third world countries, in order to decrease the pressure induced on healthcare facilities. In the struggle to treat life-threatening COVID-19 pneumonia, scientists have debated the clinical use of ionizing radiation (IR). The historical literature dating back to the 1940s contains many reports of successful treatment of pneumonia with IR. In this work, we critically review the literature for the use of IR for both diagnostic and treatment purposes. We identify details including the computed tomography (CT) scanning considerations, the radiobiological basis of IR anti-inflammatory effects, the supportive evidence for low dose radiation therapy (LDRT), and the risks of radiation-induced cancer and cardiac disease associated with LDRT. In this paper, we address concerns regarding the effective management of COVID-19 patients and potential avenues that could provide empirical evidence for the fight against the disease.