On the importance of quality assurance (QA) for COMS eye plaque Silastic inserts: A guide to measurement methods, typical variations, and an example of how QA intercepted a manufacturing aberration.

PURPOSE: Eye plaques are widely used for ocular melanoma and provide an effective alternative to enucleation with adequate tumor control. A COMS plaque utilizes a Silastic insert for precise positioning of the radioactive seeds with respect to the scleral surface of the eye; however, due to manufacturing variability, the insert may unintentionally increase or decrease the distance between the sources and tumor. The purpose of this work is to provide guidance in measuring and identifying outliers in Silastic inserts. The importance of regular quality assurance (QA) is illustrated in an experience where a systematic problem was detected and the manufacturer's 22-mm mold was corrected. METHODS: A detailed description of the molds and manufacturing process used to produce Silastic inserts is provided, including photographs of the process steps. The variability in Silastic insert production was evaluated by measuring the thickness of 124 Silastic inserts. An estimate of how the observed Silastic thickness discrepancies impact the dose to the tumor and critical eye structures was performed using homogeneous dose calculations. A standard QA protocol was developed to guide the clinical user. RESULTS: Thickness of the measured Silastic inserts ranged from 1.22 to 2.67 mm, demonstrating variation from the 2.25 mm standard. Six of the 22-mm inserts were outliers (Δthickness >3 standard deviations) and were excluded from the statistics. The outliers were investigated with the help of the manufacturer, who discovered that a systematic error was accidentally introduced into the 22-mm mold. CONCLUSIONS: Due to manufacturing errors or variability, the Silastic inserts used in COMS eye plaques may be thicker or thinner than the design standard. Such variations may impact tumor control or increase the risk of normal tissue side effects. A standardized QA program is recommended to detect variations and communicate unusual findings to the manufacturer.

Dosimetric considerations when utilizing Venezia, Capri, Rotte double tandem, and tandem and ring with interstitial needles for the treatment of gynecological cancers with high dose rate brachytherapy.

This work evaluated the difference in dosimetry of high dose rate (HDR) brachytherapy treatments between plans using advanced multichannel applicators and simplified base versions. Eighteen HDR patients treated using Interstitial Ring CT/MR Applicator Set (Elekta Brachytherapy, Netherlands) (TRN) (21 plans), CapriTM Applicator Set (Varian Medical Systems, Inc., Palo Alto, CA) (CC) (19 plans), Rotte Endometrial Applicator Set (Elekta Brachytherapy, Netherlands) (RDT) (18 plans), and the Advanced Gynecological Applicator Venezia (Vz) (Elekta Brachytherapy, Netherlands) (6 plans) were retrospectively reviewed. For each plan, "advanced" channels including any interstitial channels, the 12 noncentral channels in the CC, and the lateral extending aspects of the RDT were removed and a new plan with the original inverse planning settings was optimized using only the remaining "simplified" applicator and compared to the original. The new plans were renormalized to match the original percent dose to 90% of the high-risk clinical target volume (HR-CTV). Critical structures included bladder, rectum, sigmoid colon, and small bowel. Comparisons were made utilizing dose volume histograms of HR-CTVs, conformation number (CN), and the equivalent total dose in 2 Gy fractions (EQD2) to 2 cm3 of the normal structures. Comparing simplified to advanced plans, the average percent differences in EQD2 to 2 cm3 for Vz, with 95% confidence interval, were 101.7 ± 85.9%, 147.8 ± 76.7%, 95.3 ± 61.6%, and 44.0 ± 12.4% for Rectum, Bladder, Sigmoid, and Bowel, respectively. For TRN: 36.9 ± 18.5%, 38.2 ± 14.5%, 20.3 ± 8.8%, and 15.3 ± 8.2%. For CC: 18.9 ± 3.7%, 12.3 ± 5.3%, 27.8 ± 7.1%, and 17.1 ± 3.6%. For RDT: 1.5 ± 6.8%, 7.4 ± 6.7%, 11.1 ± 4.4%, and 8.0 ± 8.7%. The CN was better in advanced applications by 0.024 for RDT, 0.104 for TRN, 0.043 for CC, and 0.251 for Vz (all p < 0.05). Advanced multichannel treatments allow better target dose conformation and normal tissue dose manipulation. The biggest factors influencing the brachytherapy dose distributions are the number of available channels and their separation from each other within the target.

Radiation treatment to a postresection primary mucoepidermoid carcinoma (MEC) of the conjunctiva with positive margins at the Tenon's fascia-A case study.

The primary occurrence of mucoepidermoid carcinoma (MEC) of the conjunctiva is extremely rare, aggressive, and easily mistaken for squamous cell carcinoma. With fewer than 50 cases reported in the literature, there is no consensus on the most effective treatment. Radiation is an alternative to enucleation or orbital exenteration with the potential of eye preservation. We investigated several radiation approaches for a case with postresection positive margins at Tenon's fascia, and reported the patient's clinical course during the treatment and for a short time thereafter. An otherwise healthy 64-year-old male presented with MEC extending to the deep margin at the Tenon's fascia. Plans for 4 different radiation therapy treatment modalities (Intensity Modulated Radiation Therapy [IMRT], Volumetric Modulated Radiation Therapy [VMAT], double scattering (DS) proton, and reverse eye plaque low dose rate [LDR] ) were created and compared based on tumor coverage and normal tissue doses. The planning target volume (PTV) was too large and nonuniform for an eye plaque application. Using the largest plaque available (22 mm), the calculated minimum dose to the PTV was 57% while the dose to the skin was 1000% of the prescription. The proton plan completely spared the contralateral ocular structures and reduced the max doses to the ipsilateral macula and optic nerve, but was not clinically available at the time of treatment. The IMRT and VMAT plans produced similar dose distributions to each other, but VMAT further minimized dose to the ipsilateral eye. Due to the uniqueness of this case, a thorough study of the available radiation treatment options was deemed necessary. All of the external beam treatment techniques produced acceptable plans with VMAT producing the best available plan in this case. The patient was treated with the VMAT plan with a prescription of 6600 cGy in 30 fractions. At 5 months post-treatment, the patient is recovering from expected acute responses to radiation with follow ups scheduled.

Use of stereotactic body radiation therapy for medically inoperable multiple primary lung cancer.

INTRODUCTION: To review outcomes of medically inoperable patients treated with stereotactic body radiation therapy (SBRT) for multiple primary lung cancer (MPLC). METHODS: We retrospectively reviewed the charts of 10 patients (21 lesions) treated with SBRT for synchronous (seven), metachronous (one) or synchronous/metachronous lung cancers. All patients were male, medically inoperable and had a median age of 66 years. Eight patients had bilateral disease and two had unilateral disease. All patients had a histological diagnosis in at least one of the two lesions and four patients (44.4%) had both lesions biopsied. There were 18 T1 lesions and three T2 lesions. SBRT was in three fractions of 20 Gy or five fractions of 11-12 Gy to each lesion. RESULTS: Mean and median follow up were 18.8 and 15.5 months, respectively. At analysis, six patients (60.0%) are alive, and five of these living patients (83.3%) have no evidence of disease recurrence or progression. Four patients (44.4%) developed distant metastatic disease. Twenty lesions (95.2%) achieved in-field local control. No patients experienced acute pulmonary complications and only two patients (22.2%) experienced late grade I lung toxicity as per the Radiation Therapy Oncology Group toxicity criteria. CONCLUSION: SBRT for MPLC in medically inoperable patients is a safe, feasible and effective treatment approach.

Intensity modulated radiation therapy versus three dimensional conformal radiation therapy for treatment of high grade glioma: a radiobiological modeling study.

Treatment of glioblastoma results in a median survival of 12 months. Radiation dose escalation trials for high grade gliomas have resulted in modest improvements in survival in selected patients with small peripheral tumors at the expense of normal brain toxicity. Neurotoxicity includes radiation necrosis but it is increasingly recognized that long-term survivors may develop neuro-cognitive deficits. Tumor control probability (TCP) and normal tissue complication probability (NTCP) are radiobiological models used to predict treatment outcomes. This study assesses the impact of radiation dose escalation from 59.6 Gy to 90 Gy on TCP and NTCP in ten patients planned with Three Dimensional Conformal Therapy (3DCRT) and Intensity Modulated Radiation Therapy (IMRT). No difference in TCP was observed between 3DCRT and IMRT at doses of 59.4 Gy and 90 Gy. However, dose escalation to 90 Gy resulted in about 25% relative TCP increase. Compared to 3DCRT, dose escalation with IMRT significantly reduced NTCP by 70% (10.75% v. 3.75%, respectively). As a result, highly conformal techniques are recommended to obviate radiation exposure of normal brain especially when radiation dose escalation is used. Further understanding of the molecular mechanisms underlying neurotoxicity will allow the development of more precise radiobiological predictive models and of approaches to prevent or treat radiation-induced brain damage.

Stereotactic body radiation therapy (SBRT) and respiratory gating in lung cancer: dosimetric and radiobiological considerations.

The purpose of this study was to assess the impact of respiratory gating on tumor and normal tissue dosimetry in patients treated with SBRT for early stage non-small cell lung cancer (NSCLC). Twenty patients with stage I NSCLC were studied. Treatment planning was performed using four-dimensional computed tomography (4D CT) with free breathing (Plan I), near-end inhalation (Plan II), and near-end exhalation (Plan III). The prescription dose was 60 Gy in three fractions. The tumor displacement was most pronounced for lower peripheral lesions (average 7.0 mm, range 4.1-14.3 mm) when compared to upper peripheral (average 2.4mm, range 1.0-5.1 mm) or central lesions (average 2.9 mm, range 1.0-4.1 mm). In this study, the pencil beam convolution (PBC) algorithm with modified Batho power law for tissue heterogeneity was used for dose calculation. There were no significant differences in tumor and normal tissue dosimetry among the three gated plans. Tumor location however, significantly influenced tumor doses because of the necessity of respecting normal tissue constraints of centrally located structures. For plans I, II and III, average doses to central lesions were lower as compared with peripheral lesions by 4.88 Gy, 8.24 Gy and 6.93 Gy for minimum PTV and 0.98, 1.65 and 0.87 Gy for mean PTV dose, respectively. As a result, the mean single fraction equivalent dose (SFED) values were also lower for central compared to peripheral lesions. In addition, central lesions resulted in higher mean doses for lung, esophagus, and ipsilateral bronchus by 1.24, 1.93 and 7.75 Gy, respectively. These results indicate that the tumor location is the most important determinant of dosimetric optimization of SBRT plans. Respiratory gating proved unhelpful in the planning of these patients with severe COPD.