Evaluating the Impact of Bowel Gas Variations for Wilms' Tumor in Pediatric Proton Therapy.

(1) Background: Proton therapy, a precise form of radiation treatment, can be significantly affected by variations in bowel content. The purpose was to identify the most beneficial gantry angles that minimize deviations from the treatment plan quality, thus enhancing the safety and efficacy of proton therapy for Wilms' tumor patients. (2) Methods: Thirteen patients with Wilms' tumor, enrolled in the SJWT21 clinical trial, underwent proton therapy. The variations in bowel gas were systematically monitored using daily Cone Beam Computed Tomography (CBCT) imaging. Air cavities identified in daily CBCT images were analyzed to construct daily verification plans and measure water equivalent path length (WEPL) changes. A worst-case scenario simulation was conducted to identify the safest beam angles. (3) Results: The study revealed a maximum decrease in target dose (ΔD100%) of 8.0%, which corresponded to a WEPL variation (ΔWEPL) of 11.3 mm. The average reduction in target dose, denoted as mean ΔD100%, was found to be 2.8%, with a standard deviation (SD) of 3.2%. The mean ΔWEPL was observed as 3.3 mm, with an SD of 2.7 mm. The worst-case scenario analysis suggested that gantry beam angles oriented toward the patient's right and posterior aspects from 110° to 310° were associated with minimized WEPL discrepancies. (4) Conclusions: This study comprehensively evaluated the influence of bowel gas variability on treatment plan accuracy and proton range uncertainties in pediatric proton therapy for Wilms' tumor.

Cleaning the dose falloff with low modulation in SBRT lung plans.

Purpose.This dosimetric study is intended to lower the modulation factor in lung SBRT plans generated in the Eclipse TPS that could replace highly modulated plans that are prone to the interplay effect.Materials and methods.Twenty clinical lung SBRT plans with high modulation factors (≥4) were replanned in Varian Eclipse TPS version 15.5 utilizing 2 mm craniocaudal and 1 mm axial block margins followed by light optimization in order to reduce modulation. A unique plan optimization methodology, which utilizes a novel shell structure (OptiForR50) for R50%optimization in addition to five consecutive concentric 5 mm shells, was utilized to control dose falloff according to RTOG 0813 and 0915 recommendations. The prescription varied from 34-54 Gy in 1-4 fractions, and the dose objectives were PTV D95%= Rx, PTV Dmax< 140% of Rx, and minimizing the modulation factor. Plan evaluation metrics included modulation factor, CIRTOG, homogeneity index (HI), R50%, D2cm, V105%, and lung V8-12.8Gy(Timmerman Constraint). A random-intercept linear mixed effects model was used with a p ≤ 0.05 threshold to test for statistical significance.Results.The retrospectively generated plans had significantly lower modulation factors (3.65 ± 0.35 versus 4.59 ± 0.54; p < 0.001), lower CIRTOG(0.97 ± 0.02 versus 1.02 ± 0.06; p = 0.001), higher HI (1.35 ± 0.06 versus 1.14 ± 0.04; p < 0.001), lower R50%(4.09 ± 0.45 versus 4.56 ± 0.56; p < 0.001), and lower lungs V8-12.8Gy(Timmerman) (4.61% ± 3.18% versus 4.92% ± 3.37%; p < 0.001). The high dose spillage V105%was borderline significantly lower (0.44% ± 0.49% versus 1.10% ± 1.64%; p = 0.051). The D2cmwas not statistically different (46.06% ± 4.01% versus 46.19% ± 2.80%; p = 0.835).Conclusion.Lung SBRT plans with significantly lower modulation factors can be generated that meet the RTOG constraints, using our planning strategy.

Impact of mouse strain and sex when modeling radiation necrosis.

BACKGROUND: Murine models are among the most common type of preclinical animal models used to study the human condition, but a wide selection of different mice is currently in use with these differences potentially compromising study results and impairing the ability to reconcile interstudy results. Our goal was to determine how the strain and sex of the mice selection would affect the development of radiation necrosis in our murine model of radiation-induced cerebral necrosis. METHODS: We generated this model by using a preclinical irradiator to irradiate a sub-hemispheric portion of the brain of mice with single-fraction doses of 80 Gy. Eight possible combinations of mice made up of two different with two substrains each (BALB/cN, BALB/cJ, C57BL/6 N, and C57BL/6 J) and both sexes were irradiated in this study. Radiation necrosis development was tracked up to 8 weeks with a 7 T Bruker MRI utilizing T2-weighted and post-contrast T1-weighted imaging. MRI results were compared to and validated with the use of histology which utilized a scale from 0 to 3 in ascending order of damage. RESULTS: Both time post-irradiation and strain (BALB/c vs C57BL/6) were significant factors affecting radiation necrosis development. Sex was in general not a statistically significant parameter in terms of radiation necrosis development. CONCLUSION: Mouse strain thus needs to be considered when evaluating the results of necrosis models. However, sex does not appear to be a variable needing major consideration.

Minimal difference between fractionated and single-fraction exposure in a murine model of radiation necrosis.

PURPOSE: Despite the success of fractionation in clinical practice to spare healthy tissue, it remains common for mouse models used to study the efficacy of radiation therapy to use minimal or no fractionation. The goal of our study was to create a fractionated mouse model of radiation necrosis that we could compare to our single fraction model. METHODS: Precision X-Ray's X-Rad 320 cabinet irradiator was used to irradiate the cerebrum of mice with four different fractionation schemes, while a 7 T Bruker magnetic resonance imaging (MRI) scanner using T2 and post-contrast T1 imaging was used to track the development of radiation necrosis over the span of six weeks. RESULTS: All four fractionation schemes with single fraction equivalent doses (SFED) less than 50 Gy for the commonly accepted alpha/beta ratio (α/ß) value of 2-3 Gy produced radiation necrosis comparable to what would be achieved with single fraction doses of 80 and 90 Gy. This is surprising when previous work using single fractions of 50 Gy produced no visible radiation necrosis, with the results of this study showing fractionation not sparing brain tissue as much as expected. CONCLUSION: Further interpretation of these results must take into consideration other studies which have shown a lack of sparing when fractionation has been incorporated, as well as consider factors such as the use of large doses per fraction, the time between fractions, and the limitations of using a murine model to analyze the human condition.

Influence of Dose Uniformity when Replicating a Gamma Knife Mouse Model of Radiation Necrosis with a Preclinical Irradiator.

A common mouse model used for studying radiation necrosis is generated with the gamma knife, which has a non-uniform dose distribution. The goal of this study was to determine whether the lesion growth observed in this mouse model is a function of non-uniform dose distribution and/or lesion progression. Here, a model similar to the gamma knife mouse model was generated; using a preclinical irradiator, mice received single-fraction doses from 50 to 100 Gy to a sub-hemispheric portion of the brain. The development of necrosis was tracked for up to 26 weeks with a 7T Bruker magnetic resonance imaging (MRI) scanner using T2 and post-contrast T1 imaging. MRI findings were validated with histology, specifically H&E staining. Single small beam 50 Gy irradiations failed to produce necrosis in a 26-week span, while doses from 60 to 100 Gy produced necrosis in a timeframe ranging from 16 weeks to 2 weeks, respectively. Postmortem histology confirmed pathological development in regions corresponding with those that showed abnormal signal on MRI. The growth of the necrotic lesion observed in this gamma knife model was due in part to a non-uniform dose distribution rather than to the increased severity of the lesion. Interpretation of results from the gamma knife model must take into consideration the potential effect of nonuniform dose distribution, particularly with regards to the timing of interventions. There are time points in this model at which pre-onset, onset and post-onset of radiation necrosis are all represented in the irradiated field.

Interplay Effect of Target Motion and Pencil-Beam Scanning in Proton Therapy for Pediatric Patients.

PURPOSE: To investigate the effect of interplay between spot-scanning proton beams and respiration-induced tumor motion on internal target volume coverage for pediatric patients. MATERIALS AND METHODS: Photon treatments for 10 children with representative tumor motions (1-13 mm superior-inferior) were replanned to simulate single-field uniform dose- optimized proton therapy. Static plans were designed by using average computed tomography (CT) data sets created from 4D CT data to obtain nominal dose distributions. The motion interplay effect was simulated by assigning each spot in the static plan delivery sequence to 1 of 10 respiratory-phase CTs, using the actual patient breathing trace and specifications of a synchrotron-based proton system. Dose distributions for individual phases were deformed onto the space of the average CT and summed to produce the accumulated dose distribution, whose dose-volume histogram was compared with the one from the static plan. RESULTS: Tumor motion had minimal impact on the internal target volume hot spot (D2), which deviated by <3% from the nominal values of the static plans. The cold spot (D98) was also minimally affected, except in 2 patients with diaphragmatic tumor motion exceeding 10 mm. The impact on tumor coverage was more pronounced with respect to the V99 rather than the V95. Decreases of 10% to 49% in the V99 occurred in multiple patients for whom the beam paths traversed the lung-diaphragm interface and were, therefore, more sensitive to respiration-induced changes in the water equivalent path length. Fractionation alone apparently did not mitigate the interplay effect beyond 6 fractions. CONCLUSION: The interplay effect is not a concern when delivering scanning proton beams to younger pediatric patients with tumors located in the retroperitoneal space and tumor motion of <5 mm. Children and adolescents with diaphragmatic tumor motion exceeding 10 mm require special attention, because significant declines in target coverage and dose homogeneity were seen in simulated treatments of such patients.

137Cs Dosimeter Irradiation Facilities: Calibration Frequency, Precision, and Accuracy.

Many dosimeter and instrument calibration sources, especially Cs irradiators permanently installed in facilities, are infrequently calibrated since their geometry is not subject to large variation, their mechanisms are simple, and their operation can be visibly error-free for decades. Only decay corrections are needed to know delivered doses at fixed locations once a thorough characterization of such facilities is completed. For one such Cs source, however, collected current values in a span of a few days were found to drop significantly. Malfunction of the internal positioning mechanisms through wear were found to be the cause. This paper suggests periodic source calibrations for the timely identification of source failures that could cause gross errors in dose delivery. In addition, a rigorous analysis of the magnitude of uncertainties and errors in dose delivery using a calibration source is included, which is based upon newly collected experimental data. This provides a technical basis for calibration procedures to ensure a given accuracy and precision of dose delivery.

Design of Interrogation Protocols for Radiation Dose Measurements Using Optically-Stimulated Luminescent Dosimeters.

Optically-stimulated luminescent dosimeters are capable of being interrogated multiple times post-irradiation. Each interrogation removes a fraction of the signal stored within the optically-stimulated luminescent dosimeter. This signal loss must be corrected to avoid systematic errors in estimating the average signal of a series of optically-stimulated luminescent dosimeter interrogations and requires a minimum number of consecutive readings to determine an average signal that is within a desired accuracy of the true signal with a desired statistical confidence. This paper establishes a technical basis for determining the required number of readings for a particular application of these dosimeters when using certain OSL dosimetry systems.