Development of a novel fibre optic beam profile and dose monitor for very high energy electron radiotherapy at ultrahigh dose rates.

Objective. Very high energy electrons (VHEE) in the range of 50-250 MeV are of interest for treating deep-seated tumours with FLASH radiotherapy (RT). This approach offers favourable dose distributions and the ability to deliver ultra-high dose rates (UHDR) efficiently. To make VHEE-based FLASH treatment clinically viable, a novel beam monitoring technology is explored as an alternative to transmission ionisation monitor chambers, which have non-linear responses at UHDR. This study introduces the fibre optic flash monitor (FOFM), which consists of an array of silica optical fibre-based Cherenkov sensors with a photodetector for signal readout.Approach. Experiments were conducted at the CLEAR facility at CERN using 200 MeV and 160 MeV electrons to assess the FOFM's response linearity to UHDR (characterised with radiochromic films) required for FLASH radiotherapy. Beam profile measurements made on the FOFM were compared to those using radiochromic film and scintillating yttrium aluminium garnet (YAG) screens.Main results. A range of photodetectors were evaluated, with a complementary-metal-oxide-semiconductor (CMOS) camera being the most suitable choice for this monitor. The FOFM demonstrated excellent response linearity from 0.9 Gy/pulse to 57.4 Gy/pulse (R2= 0.999). Furthermore, it did not exhibit any significant dependence on the energy between 160 MeV and 200 MeV nor the instantaneous dose rate. Gaussian fits applied to vertical beam profile measurements indicated that the FOFM could accurately provide pulse-by-pulse beam size measurements, agreeing within the error range of radiochromic film and YAG screen measurements, respectively.Significance. The FOFM proves to be a promising solution for real-time beam profile and dose monitoring for UHDR VHEE beams, with a linear response in the UHDR regime. Additionally it can perform pulse-by-pulse beam size measurements, a feature currently lacking in transmission ionisation monitor chambers, which may become crucial for implementing FLASH radiotherapy and its associated quality assurance requirements.

Very high-energy electron therapy as light-particle alternative to transmission proton FLASH therapy - An evaluation of dosimetric performances.

PURPOSE: Clinical translation of FLASH-radiotherapy (RT) to deep-seated tumours is still a technological challenge. One proposed solution consists of using ultra-high dose rate transmission proton (TP) beams of about 200-250 MeV to irradiate the tumour with the flat entrance of the proton depth-dose profile. This work evaluates the dosimetric performance of very high-energy electron (VHEE)-based RT (50-250 MeV) as a potential alternative to TP-based RT for the clinical transfer of the FLASH effect. METHODS: Basic physics characteristics of VHEE and TP beams were compared utilizing Monte Carlo simulations in water. A VHEE-enabled research treatment planning system was used to evaluate the plan quality achievable with VHEE beams of different energies, compared to 250 MeV TP beams for a glioblastoma, an oesophagus, and a prostate cancer case. RESULTS: Like TP, VHEE above 100 MeV can treat targets with roughly flat (within ± 20 %) depth-dose distributions. The achievable dosimetric target conformity and adjacent organs-at-risk (OAR) sparing is consequently driven for both modalities by their lateral beam penumbrae. Electron beams of 400[500] MeV match the penumbra of 200[250] MeV TP beams and penumbra is increased for lower electron energies. For the investigated patient cases, VHEE plans with energies of 150 MeV and above achieved a dosimetric plan quality comparable to that of 250 MeV TP plans. For the glioblastoma and the oesophagus case, although having a decreased conformity, even 100 MeV VHEE plans provided a similar target coverage and OAR sparing compared to TP. CONCLUSIONS: VHEE-based FLASH-RT using sufficiently high beam energies may provide a lighter-particle alternative to TP-based FLASH-RT with comparable dosimetric plan quality.

A multicenter study of modified electron beam output calibration.

PURPOSE: This study aims to assess the accuracy of a modified electron beam calibration based on the IAEA TRS-398 and AAPM-TG-51 in multicenter radiotherapy. METHODS: This study was performed using the Elekta and Varian Linear Accelerator electron beams with energies of 4-22 MeV under reference conditions using cylindrical (PTW 30013, IBA FC65-G, and IBA FC65-P) and parallel-plate (PTW 34045, PTW 34001, and IBA PPC-40) chambers. The modified calibration used a cylindrical chamber and an updated k ' Q $k{^{\prime}}_Q$ based on Monte Carlo calculations, whereas TRS-398 and TG-51 used cylindrical and parallel-plate chambers for reference dosimetry. The dose ratio of the modified calibration procedure, TRS-398 and TG-51 were obtained by comparing the dose at the maximum depth of the modified calibration to TRS-398 and TG-51. RESULTS: The study found that all cylindrical chambers' beam quality conversion factors determined with the modified calibration ( k ' Q ) $( {{{k^{\prime}}}_Q} )$ to the TRS-398 and TG-51 vary from 0.994 to 1.003 and 1.000 to 1.010, respectively. The dose ratio of modified/TRS-398cyl and modified/TRS-398parallel-plate, the variation ranges were 0.980-1.014 and 0.981-1.019, while for the counterpart modified/TG-51cyl was found varying between 0.991 and 1.017 and the ratio of modified/TG-51parallel-plate varied in the range of 0.981-1.019. CONCLUSION: This multi-institutional study analyzed a modified calibration procedure utilizing new data for electron beam calibrations at multiple institutions and evaluated existing calibration protocols. Based on observed variations, the current calibration protocols should be updated with detailed metrics on the stability of linac components.

Evaluation of the water-equivalent characteristics of the SP34 plastic phantom for film dosimetry in a clinical linear accelerator.

In this study, some confusing points about electron film dosimetry using white polystyrene suggested by international protocols were verified using a clinical linear accelerator (LINAC). According to international protocol recommendations, ionometric measurements and film dosimetry were performed on an SP34 slab phantom at various electron energies. Scaling factor analysis using ionometric measurements yielded a depth scaling factor of 0.923 and a fluence scaling factor of 1.019 at an electron beam energy of <10 MeV (i.e., R50 < 4.0 g/cm2). It was confirmed that the water-equivalent characteristics were similar because they have values similar to white polystyrene (i.e., depth scaling factor of 0.922 and fluence scaling factor of 1.019) presented in international protocols. Furthermore, percentage depth dose (PDD) curve analysis using film dosimetry showed that when the density thickness of the SP34 slab phantom was assumed to be water-equivalent, it was found to be most similar to the PDD curve measured using an ionization chamber in water as a reference medium. Therefore, we proved that the international protocol recommendation that no correction for measured depth dose is required means that no scaling factor correction for the plastic phantom is necessary. This study confirmed two confusing points that could occur while determining beam characteristics using electron film dosimetry, and it is expected to be used as basic data for future research on clinical LINACs.

Time dynamics of the dose deposited by relativistic ultra-short electron beams.

Ultra-short electron beams are used as ultra-fast radiation source for radiobiology experiments aiming at very high energy electron beams (VHEE) radiotherapy with very high dose rates. Laser plasma accelerators are capable of producing electron beams as short as 1 fs and with tunable energy from few MeV up to multi-GeV with compact footprint. This makes them an attractive source for applications in different fields, where the ultra-short (fs) duration plays an important role. The time dynamics of the dose deposited by electron beams with energies in the range 50-250 MeV have been studied and the results are presented here. The results set a quantitative limit to the maximum dose rate at which the electron beams can impart dose.

Experimental and Monte Carlo study of energy response of BEO-based OSL detectors within photon energy range up to 15 MeV.

Response of personal dosemeters to high energy photon radiation is of great interest nowadays due to a spread of new radiation technologies and the expansion of occupational exposure domains. ICRU95 publication has expanded the range of relevant photon energies upwards, setting new horizons for individual monitoring. Beryllium oxide (BeO) material is increasingly popular due to its excellent optically stimulated luminescence (OSL) properties, simple readout and reasonable energy response in the low energy (below 100 keV) range. The study considers energy dependence of OSL response at higher photon energies. Energy deposition of monoenergetic photons with energy up to 15 MeV in the BeO chips of various thickness was modeled with Monte Carlo MCNP 6.2 code. Benchmark experiments were conducted at LINAC with high voltage of 6, 10 and 15 MV resulting in respective incident photon spectra. The findings of this study add knowledge regarding behavior of BeO personal dosemeters in the photon fields within the energy range above 3 MeV.

Dependence of Induced Biological Damage on the Energy Distribution and Intensity of Clinical Intra-Operative Radiotherapy Electron Beams.

The survival fraction of epithelial HaCaT cells was analysed to assess the biological damage caused by intraoperative radiotherapy electron beams with varying energy spectra and intensities. These conditions were achieved by irradiating the cells at different depths in water using nominal 6 MeV electron beams while consistently delivering a dose of 5 Gy to the cell layer. Furthermore, a Monte Carlo simulation of the entire irradiation procedure was performed to evaluate the molecular damage in terms of molecular dissociations induced by the radiation. A significant agreement was found between the molecular damage predicted by the simulation and the damage derived from the analysis of the survival fraction. In both cases, a linear relationship was evident, indicating a clear tendency for increased damage as the averaged incident electron energy and intensity decreased for a constant absorbed dose, lowering the dose rate. This trend suggests that the radiation may have a more pronounced impact on surrounding healthy tissues than initially anticipated. However, it is crucial to conduct additional experiments with different target geometries to confirm this tendency and quantify the extent of this effect.

Secondary radiation dose modeling in passive scattering and pencil beam scanning very high energy electron (VHEE) radiation therapy.

BACKGROUND: Electrons with kinetic energy up to a few hundred MeV, also called very high energy electrons (VHEE), are currently considered a promising technique for the future of radiation therapy (RT) and in particular ultra-high dose rate (UHDR) therapy. However, the feasibility of a clinical application is still being debated and VHEE therapy remains an active area of research for which the optimal conformal technique is also yet to be determined. PURPOSE: In this work, we will apply two existing formalisms based on analytical Gaussian multiple-Coulomb scattering theory and Monte Carlo (MC) simulations to study and compare the electron and bremsstrahlung photon dose distributions arising from two beam delivery systems (passive scattering with or without a collimator or active scanning). METHODS: We therefore tested the application of analytical and MC models to VHEE beams and assessed their performance and parameterization in the energy range of 6-200 MeV. The optimized electron beam fluence, the bremsstrahlung, an estimation of central-axis and off-axis x-ray dose at the practical range and neutron contributions to the total dose, along with an extended parameterization for the photon dose model were developed, together with a comparison between double scattering (DS) and pencil beam scanning (PBS) techniques. MC simulations were performed with the TOPAS/Geant4 toolkit to verify the dose distributions predicted by the analytical calculations. RESULTS: The results for the clinical energy range (between 6 and 20 MeV) as well as for higher energies (VHEE range between 20 and 200 MeV) and for two treatment field sizes (5 × 5 and 10 × 10 cm2 ) are reported, showing a reasonable agreement with MC simulations with mean differences below 2.1%. The relative contributions of photons generated in the medium or by the scattering system along the central-axis (up to 50% of the total dose) are also illustrated, along with their relative variations with electron energy. CONCLUSIONS: The fast analytical models parametrized in this study allow an estimation of the amount of photons produced behind the practical range by a DS system with an accuracy lower than 3%, providing important information for the eventual design of a VHEE system. The results of this work could support future research on VHEE radiotherapy.

SSRMP Recommendations No 9: Reference dosimetry in low and medium energy x-ray beams.

The SSRMP recommendations on reference dosimetry in kilovolt beams as used in radiation therapy were revised to establish current practice in Switzerland. The recommendations specify the dosimetry formalism, reference class dosimeter systems and conditions used for the calibration of low and medium energy x-ray beams. Practical guidance is provided on the determination of the beam quality specifier and all corrections required for converting instrument readings to absorbed dose to water. Guidance is also provided on the determination of relative dose under non-reference conditions and on the cross calibration of instruments. The effect of lack of electron equilibrium and influence of contaminant electrons when using thin window plane parallel chambers at x-ray tube potentials higher than 50kV is elaborated in an appendix. In Switzerland the calibration of the reference system used for dosimetry is regulated by law. METAS and IRA are the authorities providing this calibration service to the radiotherapy departments. The last appendix of these recommendations summarise this calibration chain.

FOIL ACTIVATION TECHNIQUE-A TOOL FOR THE EVALUATION OF PHOTO-NEUTRON DOSE IN RADIOTHERAPY.

Treatment of cancer is carried out using photon beams from high-energy medical linear accelerators. Photo-neutrons are also produced as an unwanted by product in the process of dose delivery to the cancer patients during their radiation treatments. In the present study, photo-neutron dose equivalents (both thermal and fast components) per unit delivered gamma-photon dose were measured at different depths, as function of distances from iso-centre in patient plane, field sizes, wedge angles and at LINAC head for a 15-MV medical linear accelerator model Elekta Precise using multi-foil activation technique. The neutron dose equivalents determined for the above-mentioned parameters were found to be lower (<0.05%) in comparison with the therapeutic photon dose delivered and within the prescribed limits recommended by the national regulatory authority.

Megavoltage radiotherapy effects on organs of the reticuloendothelial system

Purpose: To study the uptake capacity of cells from the reticuloendothelial system after irradiation with high-energy X-rays. Methods: Eighteen male Wistar rats were distributed in three groups: group A (n = 6): control, unirradiated animals studied alongside animals from group B; group B (n = 6) and group C (n = 6): animals irradiated and studied after 24 and 48 hours, respectively. The rats were anesthetized and placed on a 10 MV linear accelerator. Next, they were irradiated in the abdominal region, with 8 Gy. Twenty-four (groups A and B) and 48 hours later (group C), a colloidal carbon solution (1 mL/kg) was intravenously injected in the tail vein. Fifty minutes later, the spleens and livers were withdrawn and prepared to be studied. Kupffer cells and splenic macrophages containing carbon pigments were counted in an optical microscope. Arithmetic means were calculated for each group and compared among them. Results: X-rays were associated with a reduced number of Kupffer cells containing colloidal carbon, proliferation and enlargement of biliary ducts, hypoplasia, and hepatocyte necrosis. In the irradiated spleen, the colloidal carbon uptake was concentrated in the marginal zone around the white pulp, with an inexpressive uptake of pigments by macrophages from white and red pulps. Conclusions: The X-rays in the rat abdomen are associated with a reduction in the Kupffer cells uptake of colloidal carbon, hepatocyte disorders, bile duct proliferation, and splenic uptake of colloidal carbon concentrated in the marginal zone.

[Basic Knowledge of Neutron: Generation of Neutrons Accompanied with the High-Energy Photon Therapy].

Photo neutrons are generated from high-energy medical X-ray linacs via photo-nuclear reactions with the materials of target and collimator as well as therapeutic X-rays. Such photo neutrons sometimes make unwanted influences and are not negligible for the aspects of radiation protection and radiation control. In this article, fundamental principle of such photo-neutron generation is briefly explained. The side effects induced by the photo neutrons are summarized. In addition, some techniques of the detection and measurement of photo neutrons are introduced.

Application of a portable primary standard level graphite calorimeter for absolute dosimetry in a clinical low-energy passively scattered proton beam.

Objective. A calibration service based on a primary standard calorimeter for the direct determination of absorbed dose for proton beams does not exist. A new Code of Practice (CoP) for reference dosimetry of proton beams is being developed by a working party of the UK Institute of Physics and Engineering in Medicine (IPEM), which will recommend that ionisation chambers are calibrated directly in their clinical beams against the proposed Primary Standard Proton Calorimeter (PSPC) developed at the National Physical Laboratory (NPL). The aim of this work is to report on the use of the NPL PSPC to directly calibrate ionisation chambers in a low-energy passively scattered proton beam following recommendations of the upcoming IPEM CoP.Approach. A comparison between the dose derived using the proposed IPEM CoP and the IAEA TRS-398 protocol was performed, andkQvalues were determined experimentally for three types of chambers. In total, 9 plane-parallel and 3 cylindrical chambers were calibrated using the two protocols for two separate visits.Main results. The ratio of absorbed dose to water obtained with the PSPC and with ionisation chambers applying TRS-398 varied between 0.98 and 1.00, depending on the chamber type. The new procedure based on the PSPC provides a significant improvement in uncertainty where absorbed dose to water measured with a user chamber is reported with an uncertainty of 0.9% (1σ), whereas the TRS-398 protocol reports an uncertainty of 2.0% and 2.3% (1σ) for cylindrical and plane-parallel chambers, respectively. ThekQvalues found agree within uncertainties with those from TRS-398 and Monte Carlo calculations.Significance. The establishment of a primary standard calorimeter for the determination of absorbed dose in proton beams combined with the introduction of the associated calibration service following the IPEM recommendations will reduce the uncertainty and improve consistency in the dose delivered to patients.

Empirical modeling of the percent depth dose for megavoltage photon beams.

INTRODUCTION: This study presents an empirical method to model the high-energy photon beam percent depth dose (PDD) curve by using the home-generated buildup function and tail function (buildup-tail function) in radiation therapy. The modeling parameters n and µ of buildup-tail function can be used to characterize the Collimator Scatter Factor (Sc) either in a square field or in the different individual upper jaw and lower jaw setting separately for individual monitor unit check. METHODS AND MATERIALS: The PDD curves for four high-energy photon beams were modeled by the buildup and tail function in this study. The buildup function was a quadratic function in the form of [Formula: see text] with the main parameter of d (depth in water) and n, while the tail function was in the form of e-µd and was composed by an exponential function with the main parameter of d and µ. The PDD was the product of buildup and tail function, PDD = [Formula: see text]. The PDD of four-photon energies was characterized by the buildup-tail function by adjusting the parameters n and µ. The Sc of 6 MV and 10 MV can then be expressed simply by the modeling parameters n and µ. RESULTS: The main parameters n increases in buildup-tail function when photon energy increased. The physical meaning of the parameter n expresses the beam hardening of photon energy in PDD. The fitting results of parameters n in the buildup function are 0.17, 0.208, 0.495, 1.2 of four-photon energies, 4 MV, 6 MV, 10 MV, 18 MV, respectively. The parameter µ can be treated as attenuation coefficient in tail function and decreases when photon energy increased. The fitting results of parameters µ in the tail function are 0.065, 0.0515, 0.0458, 0.0422 of four-photon energies, 4 MV, 6 MV, 10 MV, 18 MV, respectively. The values of n and µ obtained from the fitted buildup-tail function were applied into an analytical formula of Sc = nE(S)0.63µE to get the collimator to scatter factor Sc for 6 and 10 MV photon beam, while nE, µE, S denotes n, µ at photon energy E of field size S, respectively. The calculated Sc were compared with the measured data and showed agreement at different field sizes to within ±1.5%. CONCLUSIONS: We proposed a model incorporating a two-parameter formula which can improve the fitting accuracy to be better than 1.5% maximum error for describing the PDD in different photon energies used in clinical setting. This model can be used to parameterize the Sc factors for some clinical requirements. The modeling parameters n and µ can be used to predict the Sc in either square field or individual jaws opening asymmetrically for treatment monitor unit double-check in dose calculation. The technique developed in this study can also be used for systematic or random errors in the QA program, thus improves the clinical dose computation accuracy for patient treatment.

[Radiotherapy Dosimeter Calibration for Absorbed Dose to Water Using Medical Accelerators].

A calibration service using a medical accelerator has been launched to calibrate a radiotherapy dosimeter in terms of an absorbed dose to water. The radiotherapy dosimeter calibrated by the calibration service can measure the absorbed dose to water without a beam quality conversion factor. In this paper, an overview of the calibration service for a high-energy photon beam and a high-energy electron beam was described, as well as methods of absorbed dose measurement and cross-calibration using the calibrated radiotherapy dosimeter. And the development status of a dose standard for a particle beam was reported.

Dosimetry and radioprotection evaluations of very high energy electron beams.

Very high energy electrons (VHEEs) represent a promising alternative for the treatment of deep-seated tumors over conventional radiotherapy (RT), owing to their favourable dosimetric characteristics. Given the high energy of the electrons, one of the concerns has been the production of photoneutrons. In this article we explore the consequence, in terms of neutron yield in a water phantom, of using a typical electron applicator in conjunction with a 2 GeV and 200 MeV VHEE beam. Additionally, we evaluate the resulting ambient neutron dose equivalent at various locations between the phantom and a concrete wall. Through Monte Carlo (MC) simulations it was found that an applicator acts to reduce the depth of the dose build-up region, giving rise to lower exit doses but higher entrance doses. Furthermore, neutrons are injected into the entrance region of the phantom. The highest dose equivalent found was approximately 1.7 mSv/Gy in the vicinity of the concrete wall. Nevertheless, we concluded that configurations of VHEEs studied in this article are similar to conventional proton therapy treatments in terms of their neutron yield and ambient dose equivalent. Therefore, a clinical implementation of VHEEs would likely not warrant additional radioprotection safeguards compared to conventional RT treatments.

Photoneutron-induced damage reduction for cardiac implantable electronic devices using neutron-shielding sheets in high-energy X-ray radiotherapy: A phantom study.

PURPOSE: To evaluate damage reduction in cardiac implantable electronic devices (CIEDs) caused by photoneutrons in high-energy X-ray radiotherapy using a neutron-shielding sheet (NSS). METHODS: The NSS consists of a bolus with a thickness of 1 or 2 cm (Bls1 or Bls2) as a moderator and several absorbers (20%, 50%, or 80% B4C silicone sheet [B4C20, B4C50, or B4C80] or a 40% LiF silicone sheet [LiF40]). First, a linear accelerator (LINAC) with a water-equivalent phantom was modeled in the simulation and measured experimentally. Several NSSs were placed on the phantom, a Eu:LiCaAlF6 scintillator was placed between the phantom and the NSS, and X-rays were irradiated. The relative counts (Cr = counts when placing the NSS or Bls2) were compared between the experiment and simulation. Second, CIED damage was evaluated in the simulation. The relative damage (Dr = damage when placing or not placing the NSS) was compared among all the NSSs. In addition, the γ-ray and leaking X-ray dose from B4C was measured using a dosimetric film. After determining the optimal NSS combination, Dr value analysis was performed by changing the length of one side and the thickness. RESULTS: The Cr values of the simulation and experiment agreed within a 30% percentage difference, except for Bare or LiF40-only. The Dr value was reduced by 43% when Bls2 + B4C80 was applied. The photon dose was less than 5 cGy/1500 MU. The Dr values were smaller for the smaller lengths of one side of B4C80 and decreased as the M-layer thickness increased. CONCLUSIONS: The CIED damage induced by photoneutrons generated by a LINAC was effectively reduced by applying the optimal NSS.

Stability of MRI contrast agents in high-energy radiation of a 1.5T MR-Linac.

BACKGROUND: Gadolinium-based contrast is often used when acquiring MR images for radiation therapy planning for better target delineation. In some situations, patients may still have residual MRI contrast agents in their tissue while being treated with high-energy radiation. This is especially true when MRI contrast agents are administered during adaptive treatment replanning for patients treated on MR-Linac systems. PURPOSE: The purpose of this study was to analyze the molecular stability of MRI contrast agents when exposed to high energy photons and the associated secondary electrons in a 1.5T MR-Linac system. This was the first step in assessing the safety of administering MRI contrast agents throughout the course of treatment. MATERIALS AND METHODS: Two common MRI contrast agents were irradiated with 7 MV photons to clinical dose levels. The irradiated samples were analyzed using liquid chromatography-high resolution mass spectrometry to detect degradation products or conformational alterations created by irradiation with high energy photons and associated secondary electrons. RESULTS: No significant change in chemical composition or displacement of gadolinium ions from their chelates was discovered in samples irradiated with 7 MV photons at relevant clinical doses in a 1.5T MR-Linac. Additionally, no significant correlation between concentrations of irradiated MRI contrast agents and radiation dose was observed. CONCLUSION: The chemical composition stability of the irradiated contrast agents is promising for future use throughout the course of patient treatment. However, in vivo studies are needed to confirm that unexpected metabolites are not created in biological milieus.

Conventional 3D conformal radiotherapy and volumetric modulated arc therapy for cervical cancer: Comparison of clinical results with special consideration of the influence of patient- and treatment-related parameters.

PURPOSE: Intensity-modulated radiotherapy (IMRT) for cervical cancer yields favorable results in terms of oncological outcomes, acute toxicity, and late toxicity. Limited data are available on clinical results with volumetric modulated arc therapy (VMAT). This study's purpose is to compare outcome and toxicity with VMAT to conventional 3D conformal radiotherapy (3DCRT), giving special consideration to the influence of patient- and treatment-related parameters on side effects. MATERIALS AND METHODS: Patients with cervical cancer stage I-IVA underwent radiotherapy alone or chemoradiotherapy using 3DCRT (n = 75) or VMAT (n = 30). Survival endpoints were overall survival, progression-free survival, and locoregional control. The National Cancer Institute Common Terminology Criteria for Adverse Events and the Late Effects of Normal Tissues criteria were used for toxicity assessment. Toxicity and patient- and treatment-related parameters were included in a multivariable model. RESULTS: There were no differences in survival rates between treatment groups. VMAT significantly reduced late small bowel toxicity (OR = 0.10, p = 0.03). Additionally, VMAT was associated with an increased risk of acute urinary toxicity (OR = 2.94, p = 0.01). A low body mass index (BMI; OR = 2.46, p = 0.03) and overall acute toxicity ≥grade 2 (OR = 4.17, p < 0.01) were associated with increased overall late toxicity. CONCLUSION: We demonstrated significant reduction of late small bowel toxicity with VMAT treatment, an improvement in long-term morbidity is conceivable. VMAT-treated patients experienced acute urinary toxicity more frequently. Further analysis of patient- and treatment-related parameters indicates that the close monitoring of patients with low BMI and of patients who experienced relevant acute toxicity during follow-up care could improve late toxicity profiles.

Dynamic evaluation of the prognostic value of 18F-FDG PET/CT in extranodal NK/T-cell lymphoma, nasal type.

Extranodal natural killer/T-cell lymphoma, nasal-type (ENKTL) is a type of rare and distinct entity of non-Hodgkin lymphoma with poor prognosis. It is important to evaluate the early treatment response accurately to decide further treatment strategy. 18F-FDG PET/CT plays an important role in response evaluation and prognostic prediction in some kinds of lymphomas. However, data available regarding patients with ENKTL are limited. Thus, in this prospective study, we analyzed the prognostic value of 18F-FDG PET/CT in ENKTL. Thirty-four patients with newly diagnosed ENKTL were enrolled in this phase 2 study (NCT02825147, July 7, 2016). The patients received pre-, mid-, and end-treatment 18F-FDG PET/CT scans. Deauville score (DS), maximal standardized uptake values (SUVmax), and the change in SUVmax (ΔSUVmax) were recorded for response assessment. The median follow-up period was 42.2 months. The 2-year overall survival (OS) and progression-free survival (PFS) were 82.4% and 73.5%, respectively. Univariate analysis revealed that Ann Arbor stage (P < 0.002), mid-treatment DS (P = 0.005), mid-SUVmax (P = 0.001), mid-∆SUVmax (P = 0.004), end-treatment DS (P < 0.001), and end-SUVmax (P = 0.014) were prognostic factors for OS. Ann Arbor stage (P = 0.001), mid-treatment DS (P = 0.008), mid-SUVmax (P = 0.029), mid-∆SUVmax (P < 0.001), and end-treatment DS (P =0.021) were of prognostic significance for PFS. Multivariate analysis showed that mid-SUVmax (P = 0.042) and DS at the middle (P = 0.050) and end (P = 0.044) of treatment were significant independent predictors of PFS. 18F-FDG PET/CT is useful for predicting the prognosis of ENKTL.