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Item Range modulation in proton therapy planning: a simple method for mitigating effects of increased relative biological effectiveness at the end-of-range of clinical proton beams(Springer Nature, 2014-01-02) Buchsbaum, Jeffrey C.; McDonald, Mark W.; Johnstone, Peter A. S.; Hoene, Ted; Mendonca, Marc; Cheng, Chee-Wei; Das, Indra J.; McMullen, Kevin P.; Wolanski, Mark R.; Radiation Oncology, School of MedicineBackground: The increase in relative biological effectiveness (RBE) of proton beams at the distal edge of the spread out Bragg peak (SOBP) is a well-known phenomenon that is difficult to quantify accurately in vivo. For purposes of treatment planning, disallowing the distal SOBP to fall within vulnerable tissues hampers sparing to the extent possible with proton beam therapy (PBT). We propose the distal RBE uncertainty may be straightforwardly mitigated with a technique we call "range modulation". With range modulation, the distal falloff is smeared, reducing both the dose and average RBE over the terminal few millimeters of the SOBP. Methods: One patient plan was selected to serve as an example for direct comparison of image-guided radiotherapy plans using non-range modulation PBT (NRMPBT), and range-modulation PBT (RMPBT). An additional plan using RMPBT was created to represent a re-treatment scenario (RMPBTrt) using a vertex beam. Planning statistics regarding dose, volume of the planning targets, and color images of the plans are shown. Results: The three plans generated for this patient reveal that in all cases dosimetric and device manufacturing advantages are able to be achieved using RMPBT. Organ at risk (OAR) doses to critical structures such as the cochleae, optic apparatus, hypothalamus, and temporal lobes can be selectively spared using this method. Concerns about the location of the RBE that did significantly impact beam selection and treatment planning no longer have the same impact on the process, allowing these structures to be spared dose and subsequent associated issues. Conclusions: This present study has illustrated that RMPBT can improve OAR sparing while giving equivalent coverage to target volumes relative to traditional PBT methods while avoiding the increased RBE at the end of the beam. It has proven easy to design and implement and robust in our planning process. The method underscores the need to optimize treatment plans in PBT for both traditional energy dose in gray (Gy) and biologic dose (RBE).Item Patient specific quality assurance of volumetric modulated arc therapy of synchronous bilateral breast cancer(Elsevier, 2024) Djoumessi Zamo, Francis C.; Njeh, Christopher F.; Colliaux, Anthony; Blot-Lafond, Valérie; Moyo, M. Ndontchueng; Radiation Oncology, School of MedicineSynchronous bilateral breast cancers (SBBC) present a considerable issue in external beam radiotherapy because of large fields size and large target volumes. Mono-isocentric volumetric modulated arc therapy (VMAT) appears as an appropriate irradiation technique for these types of tumors. The aim of this study was to demonstrate the utility of a 3D DVH pretreatment quality assurance program in VMAT of SBBC cases. Twenty SBBC patients who underwent radiation therapy in our department were retrospectively enrolled in this study. Fifteen patients were treated exclusively to the mammary glands. Five patients benefited from a dose boost on the tumor bed (60Gy). Nine patients were irradiated on the supraclavicular nodes (50Gy). This dose was delivered in 25 fractions and integrated boost was used when appropriate. Depending on the complexity of the treatment plans; 2 or 4 arcs VMAT plans were used in a mono-isocentric technique. The patient specific quality assurance (PSQA) was evaluated using COMPASS measured data, COMPASS reconstructed (CR) and COMPASS computed (CC) dose compared to treatment planning system (TPS) dose. Clinical evaluation was based on DVH metrics for target volumes and organ at risks. The maximum average dose deviation between TPS, CC, and CR was below 3%. The paired t-test between TPS, CC, and CR shows a strong agreement (p < 0.001). The 3DVH dose distribution comparison between TPS and COMPASS were also performed with good gamma score for global analysis. COMPASS was successfully evaluated as a 3DVH pretreatment system for SBBC despite the large fields size and complex target volumes. It allows the verification of the plan in 3D patient anatomy and the evaluation of dose discrepancies.Item Construction of Confidence Regions for Uncertain Spatial Displacements With Dual Rodrigues Parameters(ASME, 2024) Yu, Zihan; Ge, Qiaode Jeffrey; Langer, Mark P.; Radiation Oncology, School of MedicineThis paper follows our recent work on the computation of kinematic confidence regions from a given set of uncertain spatial displacements with specified confidence levels. Dual quaternion algebra is used to compute the mean displacement as well as relative displacements from the mean. In constructing a 6D confidence ellipsoid, however, we use dual Rodrigue parameters resulting from dual quaternions. The advantages of using dual quaternions and dual Rodrigues parameters are discussed in comparison with those of three translation parameters and three Euler angles, which were used for the development of the socalled the Rotational and Translational Confidence Limit (RTCL) method. The set of six dual Rodrigue parameters are used to define a parametric space in which a 6 × 6 covariance matrix and a 6D confidence ellipsoid are obtained. An inverse operation is then applied to first obtain dual quaternions and then to recover the rotation matrix and translation vector for each point on the 6D ellipsoid. Through examples, we demonstrate the efficacy of our approach by comparing it with the RTCL method known in literature. Our findings indicate that our method, based on the dual-Rodrigues formulation, yields more compact and effective swept volumes than the RTCL method, particularly in cases involving screw displacements.Item Correlation between target volume and electron transport effects affecting heterogeneity corrections in stereotactic body radiotherapy for lung cancer(Oxford University Press, 2014) Akino, Yuichi; Das, Indra J.; Cardenes, Higinia R.; Desrosiers, Colleen M.; Radiation Oncology, School of MedicineRecently, stereotactic body radiotherapy (SBRT) for lung cancer is conducted with heterogeneity-corrected treatment plans, as the correction greatly affects the dose delivery to the lung tumor. In this study, the correlation between the planning target volume (PTV) and the dose delivery is investigated by separation of the heterogeneity correction effects into photon attenuation and electron transport. Under Institutional Review Board exemption status, 74 patients with lung cancer who were treated with SBRT were retrospectively evaluated. All treatment plans were generated using an anisotropic analytical algorithm (AAA) of an Eclipse (Varian Medical Systems, Palo Alto, CA) treatment planning system. Two additional plans were created using the same treatment parameters (monitor units, beam angles and energy): a plan with no heterogeneity correction (NC), and a plan calculated with a pencil beam convolution algorithm (PBC). Compared with NC, AAA and PBC isocenter doses were on average 13.4% and 21.8% higher, respectively. The differences in the isocenter dose and the dose coverage for 95% of the PTV (D95%) between PBC and AAA were correlated logarithmically (ρ = 0.78 and ρ = 0.46, respectively) with PTV. Although D95% calculated with AAA was in general 2.9% larger than that for NC, patients with a small PTV showed a negative ΔD95% for AAA due to the significant effect of electron transport. The PTV volume shows logarithmic correlation with the effects of the lateral electron transport. These findings indicate that the dosimetric metrics and prescription, especially in clinical trials, should be clearly evaluated in the context of target volume characteristics and with proper heterogeneity correction.Item Oral and dental late effects in survivors of childhood cancer: a Children’s Oncology Group report(Springer, 2014) Effinger, Karen E.; Migliorati, Cesar A.; Hudson, Melissa M.; McMullen, Kevin P.; Kaste, Sue C.; Ruble, Kathy; Guilcher, Gregory M. T.; Shah, Ami J.; Castellino, Sharon M.; Radiation Oncology, School of MedicinePurpose: Multi-modality therapy has resulted in improved survival for childhood malignancies. The Children's Oncology Group Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers provide practitioners with exposure- and risk-based recommendations for the surveillance and management of asymptomatic survivors who are at least 2 years from completion of therapy. This review outlines the pathophysiology and risks for oral and dental late effects in pediatric cancer survivors and the rationale for oral and dental screening recommended by the Children's Oncology Group. Methods: An English literature search for oral and dental complications of childhood cancer treatment was undertaken via MEDLINE and encompassed January 1975 to January 2013. Proposed guideline content based on the literature review was approved by a multi-disciplinary panel of survivorship experts and scored according to a modified version of the National Comprehensive Cancer Network "Categories of Consensus" system. Results: The Children's Oncology Group oral-dental panel selected 85 relevant citations. Childhood cancer therapy may impact tooth development, salivary function, craniofacial development, and temporomandibular joint function placing some childhood cancer survivors at an increased risk for poor oral and dental health. Additionally, head and neck radiation and hematopoietic stem cell transplantation increase the risk of subsequent malignant neoplasms in the oral cavity. Survivors require routine dental care to evaluate for potential side effects and initiate early treatment. Conclusions: Certain childhood cancer survivors are at an increased risk for poor oral and dental health. Early identification of oral and dental morbidity and early interventions can optimize health and quality of life.Item Introduction to the Special LDLensRad Focus Issue(BioOne, 2022) Ainsbury, Elizabeth A.; Dalke, Claudia; Mancuso, Mariateresa; Kadhim, Munira; Quinlan, Roy A.; Azizova, Tamara; Dauer, Lawrence T.; Dynlacht, Joseph R.; Tanner, Rick; Hamada, Nobuyuki; Radiation Oncology, School of MedicineRecent epidemiological and experimental animal data, as well as reanalyses of data previously accumulated, indicate that the lens of the eye is more radiosensitive than was previously thought. This has resulted in a reduction of the occupational lens dose limit within the European Union countries, Japan and elsewhere. This Commentary introduces the work done by the LDLensRad Consortium contained within this Focus Issue, towards advancement of understanding of the mechanisms of low dose radiation cataract.Item Palliative whole brain radiation therapy: an international state of practice(AME, 2023-11) Keit, Emily; Lee, Shing Fung; Woodward, Melissa; Rembielak, Agata; Shiue, Kevin; Desideri, Isacco; Oldenburger, Eva; Bienz, Maya; Rades, Dirk; Theodorou, Marilena; Agyeman, Mervin B.; Yarney, Joel; Bryant, John Michael; Yu, Hsiang-Hsuan Michael; Simone, Charles B., II; Hoskin, Peter; Johnstone, Peter A. S.; Radiation Oncology, School of MedicineBackground: Improvements in radiation delivery and systemic therapies have resulted in few remaining indications for palliative whole brain radiation therapy (WBRT). Most centers preferentially use stereotactic radiotherapy (SRT) and reserve WBRT for those with >15 lesions, leptomeningeal presentation, rapidly progressive disease, or limited estimated survival. Despite regional differences among preferred dose, fractionation, and treatment technique, we predict survival post-WBRT will remain poor—indicating appropriate application of WBRT in this era of SRT and improved systemic therapies. Methods: A multi-center, international retrospective analysis of patients receiving WBRT in 2022 was performed. Primary end point was survival after WBRT. De-identified data were analyzed centrally. Patients receiving WBRT as part of a curative regimen, prophylactically, or as bridging therapy were excluded. The collected data consisted of patient parameters including prescription dose and fractionation, use of neurocognitive sparing techniques and survival after WBRT. Survival was calculated via the Kaplan-Meier method. Results: Of 29,943 international RT prescriptions written at ten participating centers in 2022, 462 (1.5%) were for palliative WBRT. Participating centers were in the United States (n=138), the United Kingdom (n=111), Hong Kong (n=72), Italy (n=49), Belgium (n=45), Germany (n=27), Ghana (n=15), and Cyprus (n=5). Twenty-six different dose regimens were used. The most common prescriptions were for 3,000 cGy over 10 fractions (45.0%) and 2,000 cGy over 5 fractions (43.5%) with significant regional preferences (P<0.001). Prior SRT was delivered in 32 patients (6.7%), hippocampal avoidance (HA) was used in 44 patients (9.5%), and memantine was prescribed in 93 patients (20.1%). Survival ranged from 0 days to still surviving at 402 days post-treatment. The global median overall survival (OS) was 84 days after WBRT [95% confidence interval (CI): 68.0–104.0]. Actuarial survival at 7 days, 1 month, 3 months, and 6 months were 95%, 78%, 48%, and 32%, respectively. Twenty-seven patients (5.8%) were unable to complete their prescribed WBRT. Conclusions: This moment-in-time analysis confirms that patients with poor expected survival are being appropriately selected for WBRT—illustrating the dwindling indications for WBRT—and demonstrates the variance in global practice. Since poor survival precludes patients from deriving benefit, memantine and HA are best suited in carefully selected cases.Item FCB-CHOPS: An Evolution of a Commonly Used Acronym for Evaluating Radiation Treatment Plans(Elsevier, 2024-11-26) Weisman, Michael; McClelland, Shearwood, III; Agrawal, Namita; Jimenez, Rachel B.; Yechieli, Raphael; Fields, Emma; Ishaq, Omar; Holmes, Jordan A.; Golden, Daniel W.; Mak, Raymond; Shiue, Kevin; Radiation Oncology, School of MedicineChecklists have been used across many fields as a systematic framework to reduce human error and improve safety. In radiation oncology, the CB-CHOP acronym was previously developed as a tool to aid physicians in assessing the quality of radiation treatment plans for approval. This manuscript updates the acronym for the modern era with the addition of F and S to create FCB-CHOPS: fusion, contours, beams, coverage, heterogeneity, organs at risk, prescription, and dose summation. These 2 additions reflect the evolution and importance of image fusion to aid in the delineation of targets and organs at risk and dose summation to reflect the increased incidence of reirradiation and the need to consider prior treatment courses in the final plan evaluation. Utilization of this and similar checklists is critical in maintaining high-quality and safe radiation oncology treatments.Item Global representatives initiative of the American Association of Physicists in Medicine(AAPM, 2023) Lief, E.; Weygand, J.; Parker, S. A.; Biancia, C. Della; Barreto, I.; Njeh, C.; Ngwa, W.; Radiation Oncology, School of MedicineNew initiatives in the international relations of the American Association of Physicists in Medicine include determining the most imminent needs of low- and middle-income countries. A global needs survey was designed by members of the newly formed Global Needs Assessment Committee, Global Representatives Subcommittee and Equipment Donation Committee. To better understand the current needs and optimal ways of addressing them, we created a network of global representatives that serve as consultants on our committees. In addition, our members participated in several regional conferences with direct interaction with attendees from low- and middle-income countries. Based on the determined needs, we are suggesting new ways to address training of our colleagues overseas, providing them with better equipment and facilitating interactions with industry.Item Mean Heart Dose Is an Inadequate Surrogate for Left Anterior Descending Coronary Artery Dose and the Risk of Major Adverse Cardiac Events in Lung Cancer Radiation Therapy(Elsevier, 2021) Atkins, Katelyn M.; Bitterman, Danielle S.; Chaunzwa, Tafadzwa L.; Kozono, David E.; Baldini, Elizabeth H.; Aerts, Hugo J. W. L.; Tamarappoo, Balaji K.; Hoffmann, Udo; Nohria, Anju; Mak, Raymond H.; Radiation Oncology, School of MedicinePurpose: Mean heart dose (MHD) over 10 Gy and left anterior descending (LAD) coronary artery volume (V) receiving 15 Gy (V15Gy) greater than 10% can significantly increase the risk of major adverse cardiac events (MACE) in patients with non-small cell lung cancer (NSCLC). We sought to characterize the discordance between MHD and LAD dose and the association of this classification on the risk of MACE after radiation therapy. Methods and materials: The coefficient of determination for MHD and LAD V15Gy was calculated in this retrospective analysis of 701 patients with locally advanced NSCLC treated with radiation therapy. Four groups were defined on the basis of high or low MHD (≥10 Gy vs <10 Gy) and LAD V15Gy (≥10% vs <10%). MACE (unstable angina, heart failure, myocardial infarction, coronary revascularization, and cardiac death) cumulative incidence was estimated, and Fine and Gray regressions were performed. Results: The proportion of variance in LAD V15Gy predictable from MHD was only 54.5% (R2 = 0.545). There was discordance (where MHD was high [≥10 Gy] and LAD low [V15Gy < 10%], or vice versa) in 23.1% of patients (n = 162). Two-year MACE estimates were 4.2% (MHDhigh/LADlow), 7.6% (MHDhigh/LADhigh), 1.8% (MHDlow/LADlow), and 13.0% (MHDlow/LADhigh). Adjusting for pre-existing coronary heart disease and other prognostic factors, MHDhigh/LADlow (subdistribution hazard ratio [SHR], 0.34; 95% CI, 0.13-0.93; P = .036) and MHDlow/LADlow (SHR, 0.24; 95% CI, 0.10-0.53; P < .001) were associated with a significantly reduced risk of MACE. Conclusions: MHD is insufficient to predict LAD V15Gy with confidence. When MHD and LAD V15Gy dose exposure is discordant, isolated low LAD V15Gy significantly reduces the risk of MACE in patients with locally advanced NSCLC after radiation therapy, suggesting that the validity of whole heart metrics for optimally predicting cardiac events should be reassessed.