Final Treatment Plan Research Articles

Is low-dose anticoagulation a therapeutic option for patients at high risk of bleeding with high-risk pulmonary thromboembolism

This issue of Chinese Journal of Tuberculosis and Respiratory Diseases published an interesting case illustrating the identification, treatment, and post-treatment management of a high-risk pulmonary thromboembolism (PTE) that occurred during surgery. It was a high-risk case of PTE, but during treatment, the risk stratification changed to medium-high risk. We should dynamically assess risk stratification and develop diagnosis and treatment plans based on changes in the patient's condition. At the same time, there was a high risk of bleeding in this patient. We should try to decrease the risk of bleeding as much as possible, consider all the conditions that can be applied at that time and on a local level, and devise a safe and effective treatment plan. The socio-economic status of patients may have an impact on how the final diagnosis and treatment plan are implemented. We need to communicate fully with patients, consider comprehensively, and prepare contingency plans to ensure patients' life safety to the greatest extent possible.

Automated Cephalometric Landmark Detection: A Novel Software Model Compared with Manual Annotation Method

Introduction AI-based automated cephalometric landmark detection streamlines orthodontic diagnosis and treatment planning, providing accurate, efficient, and reliable results. Benefits include saving time, minimizing subjectivity, improving precision, and facilitating continuous improvement. However, they should complement clinician expertise, ensuring qualified orthodontists make the final diagnosis and treatment plan. Aim To propose a method that automatically detects cephalometric landmarks on the X-ray images and compare these values with the manual annotation method. Methodology A dataset of 600 X-ray images, each containing 19 landmarks, was collected. Two orthodontists manually marked the 19 landmarks in 300 cephalograms and their coordinates were automatically extracted. The dataset was cleaned for errors, and a pre-trained CNN model with an EfficientNetB7 backbone was used for landmark detection. The model was trained on 80% of the dataset and tested on the remaining 20%. The two-step method included ROI extraction and landmark detection. The RMSE score was used to evaluate inter-examiner reliability and the R2 score was used to compare manual and automated models. Result Model landmark locations were compared to the manual method. The mean deviation of the predicted landmarks from the actual landmarks was calculated using RMSE, and the model showed acceptable accuracy compared to manual annotation. EfficientNetB7 was found to have detection accuracies similar to the manual annotation method. For landmarks like Porion, articulare, and soft tissue pogonion, the model outperformed the human annotation method and provides a consistent better result, and for points like Point A, pogonion, gnathion, and menton, the manual methods show more accurate results. Conclusion The study introduced an automated approach using deep learning to predict landmark locations, and the results demonstrate its accuracy in comparison with the manual annotation method. This approach effectively detects cephalometric landmarks, suggesting its potential for clinical use with orthodontist’s supervision.

The Role of Magnetic Resonance Imaging in the Preoperative Staging and Treatment of Invasive Lobular Carcinoma

IntroductionInvasive lobular carcinoma (ILC) is known for its diffuse growth pattern and its associated challenges in diagnosing. Magnetic resonance imaging (MRI) is the most accurate imaging modality and might aid in improving preoperative staging compared to full field digital mammography (FFDM) and ultrasound (US), however current literature is inconsistent. The aim of this paper is to evaluate the accuracy of MRI staging compared to FFDM/US and pathology results. MethodsIn this single-centre retrospective study, all patients diagnosed with ILC between 2014 and 2019 who underwent preoperative MRI were included. Specific parameters studied were: (1) the need for second-look targeted biopsies, (2) detection of new tumors (ie, contralateral or multifocal), (3) changes in cTNM-classification, and (4) impact on final treatment plan. Bland-Altman plots were used to compare the tumor sizes measured on MRI and FFDM/US with actual pathological tumor sizes. ResultsNinety-nine patients were included. After performing preoperative MRI, 9 (9.1%) multifocal tumors were diagnosed after additional biopsies. Contralateral tumors were detected twice (2.0%) and cN classification was upgraded in 7 cases (7.1%). Surgical treatment or neoadjuvant treatment plans were changed in 16 patients (16.1%). Compared to histopathological results, FFDM/US underestimated tumor size with a mean of 0.4 cm (Limit of agreement (LoA): -2.8 cm to 2.0 cm) whereas MRI overestimated tumor size with a mean of 0.6 cm (LoA: -1.9 cm to 3.0 cm). ConclusionsIn our study, mean differences in tumor size measurements using FFDM/US and MRI were comparable, with similar random errors. MRI correctly diagnosed multifocal and contralateral tumors more often and provided a better cN staging.

Deep learning based MLC aperture and monitor unit prediction as a warm start for breast VMAT optimisation

Objective. Automated treatment planning today is focussed on non-exact, two-step procedures. Firstly, dose–volume histograms (DVHs) or 3D dose distributions are predicted from the patient anatomy. Secondly, these are converted in multi-leaf collimator (MLC) apertures and monitor units (MUs) using a generic optimisation to obtain the final treatment plan. In contrast, we present a method to predict volumetric modulated arc therapy (VMAT) MLC apertures and MUs directly from patient anatomy using deep learning. The predicted plan is then provided as initialisation to the optimiser for fine-tuning. Approach. 148 patients (training: 101; validation: 23; test: 24), treated for right breast cancer, are replanned to obtain a homogeneous database of 3-arc VMAT plans (PTVBreast: 45.57 Gy; PTVBoost: 55.86 Gy) according to the clinical protocol, using RapidPlanTM with automatic optimisation and extended convergence mode (clinical workflow). Projections of the CT and contours are created along the beam’s eye view of all control points and given as input to a U-net type convolutional neural networks (CNN). The output are the MLC aperture and MU for all control points, from which a DICOM RTplan is built. This is imported and further optimised in the treatment planning system using automatic optimisation without convergence mode, with clinical PTV objectives and organs-at-risk (OAR) objectives based on the DVHs calculated from the imported plan (CNN workflow). Main results. Mean dose differences between the clinical and CNN workflow over the test set are 0.2 ± 0.5 Gy at D 95% and 0.6 ± 0.4 Gy at D 0.035cc of PTVBreast and −0.4 ± 0.3 Gy at D 95% and 0.7 ± 0.3 Gy at D 0.035cc of PTVBoost. For the OAR, they are −0.2 ± 0.2 Gy for D mean,heart and 0.04 ± 0.8 Gy for D mean,ipsilateral lung. The mean computation time is 60 and 25 min respectively. Significance. VMAT optimisation can be initialised by MLC apertures and MUs, directly predicted from patient anatomy using a CNN, reducing planning time with more than half while maintaining clinically acceptable plans. This procedure puts the planner in a supervising role over an AI-based treatment planning workflow.

Will supplemental cone beam computed tomography change the treatment plan of impacted maxillary canines based on 2D radiography? A prospective clinical study.

To evaluate the impact of cone beam computed tomography (CBCT) on treatment planning for impacted maxillary canines; secondly, to identify CBCT factors influencing a change in the treatment plan; and thirdly, to assess 2D radiographic factors that can aid in selecting appropriate candidates for CBCT. Patients with impacted maxillary canines and an overlap of a neighboring tooth in 2D radiographs and the suspicion of root resorption were referred for CBCT examination. An initial treatment plan was based on 2D radiographs, and the final treatment plan was established after the CBCT examination. Logistic regression analyses and t-tests were performed to evaluate differences in radiographic findings between the groups with and without a change in treatment plan. The study prospectively included 125 impacted canines, and 43 (34.4%) of them had a change in treatment plan after the CBCT examination. The most common change was a modification in the direction of cantilever traction (n = 28; 22.4%), while the least common was the change in decision to remove/keep the canine (n = 4; 3.2%). The size of the alpha and lateral angles had a significant impact on the decision to change the treatment plan. Other radiographic findings did not influence a change in treatment plan. One-third of the canines had a change in treatment plan after supplemental CBCT examination. Canines with large alpha and lateral angles measured in the panoramic image were found to be significantly more likely to undergo changes in the initial direction of cantilever traction or changes to the canine extraction strategy following CBCT examination.

Nonextraction Orthodontic Treatment of Severely Impacted Maxillary Canines through Transalveolar Transplantation in a 10-Year-Old Patient: A Case Report with a 6-Year Follow-Up Period

Objective: This case report describes the interdisciplinary treatment of a 10-year-old girl with asymmetric Class III malocclusion, severe maxillary crowding, and bilaterally impacted maxillary canines. Clinical considerations: The clinical decision-making factors regarding treatment alternatives and the final treatment plan are discussed. A two-phase nonextraction therapy was implemented to relieve severe crowding, eliminate the maxillary canine impactions, and compensate for skeletal Class III malocclusion. The first treatment phase involved aligning the left canine through conventional orthodontic traction, while the more deeply horizontally impacted right canine was corrected through transalveolar transplantation. In the second phase, the Class III dental relationship was corrected through mandibular molar retraction. The effective use of various temporary skeletal anchorage devices such as modified c-palatal plates and mini-implants was illustrated. Conclusions: At the end of the treatment, esthetic dental alignment was achieved, along with improved facial balance. The transplanted maxillary right canine showed good health and a favorable long-term prognosis over six years after the procedure.

Does cone beam CT change the treatment decision for maxillary second and third molars? A prospective study.

To evaluate whether information from CBCT changes the treatment plan for maxillary second and third molars and to examine clinical and radiographic parameters with an impact on treatment decision. This prospective study included 260 maxillary third molars with superimposition onto the second molar in panoramic images (170 patients; mean age 28 years, range 16-63). An initial treatment plan was based on clinical findings and panoramic images. After CBCT, a final treatment plan was decided. Treatment was undertaken based on the final treatment plan. Through logistic regression analyses, impact of clinical and radiographic parameters on change in treatment plan, removal of the third molar vs no treatment, and removal of the second vs third molar were evaluated. The treatment plan changed in 82 cases (32%). Sixteen cases (6%) changed from removal of the third molar to removal of the second molar. Regression analyses showed that severe resorption in the second molar was significantly related to a change in treatment plan. Removal of a third molar was decided in 180 cases and regression analyses identified that mesioangulation of the third molar, marginal bone loss, superficial resorption, and age were significantly related to removal of the third molar vs no treatment. Thirty second molars were removed, and regression analyses showed that severe resorption was significantly related to removal of the second molar instead of the third molar. Parameters such as resorption evaluated in CBCT can modify the treatment decision, resulting in removal of the second and/or the third molar.

Sense and nonsense of yT-staging on MRI after chemoradiotherapy in rectal cancer.

The aim of this work was to investigate the value of rectal cancer T-staging on MRI after chemoradiotherapy (ymrT-staging) in relation to the degree of fibrotic transformation of the tumour bed as assessed using the pathological tumour regression grade (pTRG) of Mandard as a standard of reference. Twenty two radiologists, including five rectal MRI experts and 17 'nonexperts' (general/abdominal radiologists), evaluated the ymrT stage on the restaging MRIs of 90 rectal cancer patients after chemoradiotherapy. The ymrT stage was compared with the final ypT stage at histopathology; the percentages of correct staging (ymrT = ypT), understaging (ymrT < ypT) and overstaging (ymrT > ypT) were calculated and compared between patients with predominant tumour at histopathology (pTRG4-5) and patients with predominant fibrosis (pTRG1-3). Interobserver agreement (IOA) was computed using Krippendorff's alpha. Average ymrT/ypT stage concordance was 48% for the experts and 43% for the nonexperts; ymrT/ypT stage concordance was significantly higher in the pTRG4-5 subgroup (58% vs. 41% for the pTRG1-3 group; p = 0.01), with the best results for the MRI experts. Overstaging was the main source of error, especially in the pTRG1-3 subgroup (average overstaging rate 38%-44% vs. 13%-55% in the pTRG4-5 subgroup). IOA was higher for the expert versus nonexpert readers (α = 0.67 vs. α = 0.39). ymrT-staging is moderately accurate; accuracy is higher in poorly responding patients with predominant tumour but low in good responders with predominant fibrosis, resulting in significant overstaging. Radiologists should shift their focus from ymrT-staging to detecting gross residual (and progressive) disease, and identifying potential candidates for organ preservation who would benefit from further clinical and endoscopic evaluation to guide final treatment planning.

Diagnostic aids in dentistry-An overview

Oral Diagnosis” simply represents “analysis of the inner mouth”. An effective treatment for any oral disease is only feasible if correct and precise diagnosis has been made. In field of dentistry oral diagnosis involves examination and finding all problems inside and outside of the oral cavity by using scientific knowledge and also to find the relationship between them. Thus helping in making final accurate treatment plan based on the collected findings. Efficient treatment for any dental problem needs accurate diagnosis. Diagnosis involves collection of information by history taking and clinical examination of patient which is confirmed by using various diagnostic aids and more precise and elaborated information is obtained from these diagnostic aids. This paper will discuss various diagnostic aids used in dentistry.

PINDBORG TUMOR PRESENTING IN EARLY ADOLESCENT- A RARE CASE REPORT

As infrequent as it may be, a calcifying odontogenic tumor As infrequent as it may be, a calcifying odontogenic tumor is more commonly seen in the late decades of life. It is a locally aggressive lesion that might interfere function by virtue of its expansile growth through the cortices of the involved jaw. This is a case report of Pindborg tumor in 11 year old male in the right mandibular body region and a rundown on the various investigations done and the final treatment plan adopted. A review of literature on the lesion and justification for the chosen treatment modality is included.

What is the Value of Radiology Input During a Multidisciplinary Orthopaedic Oncology Conference?

Multidisciplinary orthopaedic oncology conferences are important in developing the treatment plan for patients with suspected orthopaedic bone and soft tissue tumors, involving physicians from several services. Past studies have shown the clinical value of these conferences; however, the impact of radiology input on the management plan and time cost for radiology to staff these conferences has not been fully studied. (1) Does radiology input at multidisciplinary conference help guide clinical management and improve clinician confidence? (2) What is the time cost of radiology input for a multidisciplinary conference? This prospective study was conducted from October 2020 to March 2022 at a tertiary academic center with a sarcoma center. A single data questionnaire for each patient was sent to one of three treating orthopaedic oncologists with 41, 19, and 5 years of experience after radiology discussion at a weekly multidisciplinary conference. A data questionnaire was completed by the treating orthopaedic oncologist for 48% (322 of 672) of patients, which refers to the proportion of those three oncologists' patients for which survey data were captured. A musculoskeletal radiology fellow and musculoskeletal fellowship-trained radiology attending physician provided radiology input at each multidisciplinary conference. The clinical plan (leave alone, follow-up imaging, follow-up clinically, recommend different imaging test, core needle biopsy, surgical excision or biopsy or fixation, or other) and change in clinical confidence before and after radiology input were documented. A second weekly data questionnaire was sent to the radiology fellow to estimate the time cost of radiology input for the multidisciplinary conference. In 29% (93 of 322) of patients, there was a change in the clinical plan after radiology input. Biopsy was canceled in 30% (24 of 80) of patients for whom biopsy was initially planned, and surgical excision was canceled in 24% (17 of 72) of patients in whom surgical excision was initially planned. In 21% (68 of 322) of patients, there were unreported imaging findings that affected clinical management; 13% (43 of 322) of patients had a missed finding, and 8% (25 of 322) of patients had imaging findings that were interpreted incorrectly. For confidence in the final treatment plan, 78% (251 of 322) of patients had an increase in clinical confidence by their treating orthopaedic oncologist after the multidisciplinary conference. Radiology fellows and attendings spent a mean of 4.2 and 1.5 hours, respectively, reviewing and presenting at a multidisciplinary conference each week. The annual combined prorated time cost for the radiology attending and fellow was estimated at USD 24,310 based on national median salary data for attendings and internal salary data for fellows. In a study taken at one tertiary-care oncology program, input from radiology attendings and fellows in the setting of a multidisciplinary conference helped to guide the final treatment plan, reduce procedures, and improve clinician confidence in the final treatment plan, at an annual time cost of USD 24,310. Multidisciplinary orthopaedic oncology conferences can lead to changes in management plans, and the time cost to the radiologists should be budgeted for by the radiology department or parent institution.

Predictability of orthodontic tooth movement with aligners: effect of treatment design

BackgroundsThe present study was designed to define: (1) which are the less predictable OTM with Invisalign aligners when the treatment plan is designed by expert operators, (2) if the presence and shape of attachments influence the predictability of OTM and (3) if patients’ demographics influence OTM predictability. The sample comprises 79 prospectively recruited patients (mean age 30.8 years; SD 12.0; 23 M, 56 F), treated by expert operators with an average of 27 aligners (SD 15) in the maxillary arch and 25 aligners (SD 11) in the mandibular arch. Post-treatment digital models and final virtual treatment plan models were exported from ClinCheck® software as STL files and subsequently imported into Geomagic Qualify ®software, to compare final teeth positions. The differences were calculated and tested for statistical significance for each tooth in the mesial–distal, vestibular–lingual and occlusal–gingival directions, as well as for angulation, inclination and rotation. In addition, the statistical significance of categorical variables was tested.ResultsThe lack of correction was significant for all movements and in all group of teeth (P < 0.01) except for the rotation of maxillary first molar. The prescribed OTM, the group of teeth and movement, the frequency of aligner change and the use of attachment influence the outcome. The greatest discrepancies in predicted and achieved tooth position were found for angular movements and rotation of teeth characterized by round-shaped crowns, for a ratio of approximately 0.4° per 1° prescribed. Optimized attachments for upper canines and lower premolar rotation seem not working properly. Second molar movements are mostly unexpressed. Furthermore, changing the aligner every 14 days will reduce the lack of correction of the 12% with respect to 7 days aligner change.ConclusionsPredictability of orthodontic movement with aligners still has limitations related to the biomechanics of the system: the shape of some attachments and the characteristics of aligner material need to be redefined. However, the results of this study allow to properly design the virtual treatment plan, revealing how much overcorrection is needed and which attachments are most effective.

Management principles of cranial base tumor with aneurysm.

Skull base tumors are challenging to treat because of their deep location, complex anatomy, and close proximity to important blood vessels and nerves. Furthermore, some patients with cranial tumors are found to have aneurysms, but there is no consensus on how to evaluate the impact of aneurysms on surgery and how to handle the lesions safely and effectively. We retrospectively reviewed our database to identify all patients with a skull base tumor treated in the Department of Neurosurgery of Beijing Tiantan Hospital affiliated with Capital Medical University from 2019 to 2021. The records of patients with skull base tumors associated with aneurysms were analyzed. The operative methods and postoperative follow-up information were collected. We analyzed a total of 481 patients with skull base tumors, comprising 224 males and 257 females with a mean age of 48 ± 14years. Twenty-four patients (24/481, 5.0%) were diagnosed with aneurysms. For eight patients, it was considered necessary to perform aneurysm treatment before or during the tumor resection surgery. For the other 16 patients, the recommendation was to monitor the aneurysm or perform elective aneurysm treatment after tumor resection. All patients with both skull base tumors and aneurysms benefited from treatment. No severe postoperative complications occurred. We summarized the final treatment plan for all patients with skull base tumors with aneurysms and proposed a protocol to decrease the surgical risk of patients with skull base tumors associated with aneurysms.

Impact of patients' sex in assessments and treatment recommendations in an older adult cancer clinic

IntroductionIn multiple settings, sex disparities have been seen in diagnosis, treatment, and outcomes. This study sought to determine whether there are sex differences in a geriatric oncology clinic concerning results of the comprehensive geriatric assessment (CGA) and treatment recommendations. Materials and MethodsThis is a retrospective cohort study including patients ≥65 years old referred for consultation on cancer treatment decision-making who underwent a CGA between July 2015 and December 2020, in a single Canadian academic geriatric oncology (GO) clinic. We examined differences by sex, stratified by disease site, stage, treatment intent, CGA results by domain, final treatment plan, and referrals for abnormal CGA findings. Differences were assessed using chi-square, Fisher's exact, or t-test as appropriate. Multivariate logistic regression was performed to examine whether sex impacted recommendations to reduce treatment intensity. ResultsIn the study period, 328 patients were assessed in the GO clinic (mean age 81 years). The most common cancer types were gastrointestinal (42.1%), hematologic (18.3%), and head and neck (17.3%). More males than females were assessed in the GO clinic (62.2% versus 37.8%, respectively). This proportion did not change over time (p = 0.58). The GO clinic recommended to reduce treatment intensity in 140 cases (42.7%), with no difference between sexes in adjusted models (43.6% of females and 42.2% of males, p = 0.80). There were no differences in any CGA domain by sex. There were also no differences in referrals made by the GO clinic to optimize abnormal CGA domains by sex. DiscussionSex itself did not impact treatment decision-making, nor referrals to optimize abnormal CGA domains in our GO clinic using CGA-based care.

Treatment planning for a patient requiring multiple restorative treatment modalities by a recently qualified dentist

This article presents a case demonstrating the treatment of a patient using multiple restorative modalities, including endodontics, indirect restorations and prosthetics. The patient's oral condition resulted from a high cariogenic diet, particularly a destructive carbonated drink habit. This case discusses the treatment options for each diagnosis and the rationale behind the final treatment plan. There was a considerable focus on prevention and restoration of teeth in order to achieve optimal oral health and function, as this was the patient's expressed priority. CPD/Clinical Relevance: Patients with high cariogenic diets present with varying restorative needs within general practice, and this report demonstrates the treatment of a simple case.

Toward real-time automatic treatment planning (RTTP) with a one-step 3D fluence map prediction method and (nonorthogonal) convolution technique

PurposeTo establish and evaluate a (quasi) real-time automated treatment planning (RTTP) strategy utilizing a one-step full 3D fluence map prediction model based on a nonorthogonal convolution operation for rectal cancer radiotherapy. MethodsThe RTTP approach directly extracts 3D projections from volumetric CT and anatomical data according to the beam incident direction. A 3D deep learning model with a nonorthogonal convolution operation was established that takes projections in cone beam space as input, extracts the features along and around the ray-trace path, and outputs a predicted fluence map (PFM) for each beam. The PFM is then converted to the MLC sequence with deliverable MUs to generate the final treatment plan. A total of 314 rectal adenocarcinoma patients with 2198 projection data samples were used in model training and validation. An extra 20 patients were used to test the feasibility of the RTTP method by comparing the plan quality, efficiency, deliverability performance, and physician blinded review results with the manual plans. ResultsOverall, the RTTP plans met the clinical dose criteria for target coverage, conformity, homogeneity, and organ-at-risk dose sparing. Compared to manual plans, the RTTP plans showed increases in PTV D1% by only 2.33% (p < 0.001) and a decrease in PTV D99% by 0.45% (p < 0.05). The RTTP plans showed a dose increase in the bladder, with a V50 of 14.01 ± 11.75% vs. 10.74 ± 8.51%, respectively, and no significant increases in the femoral head with the mean dose. The planning efficiency was improved in RTTP planning, with 39 s vs. 944 s in fluence map generation; the deliverability performance was saved by 1.91% (p < 0.001) in total MU. According to the blinded plan review by our physician, 55% of RTTP plans can be directly used in clinical radiotherapy treatment. ConclusionThe quasi RTTP method improves the planning efficiency and deliverability performance while maintaining a plan quality close to that of the optimized manual plans in rectal radiotherapy.

Robustness Evaluation for Proton Therapy with a Spirometry Based Deep Inhalation Breath Hold System

<h3>Purpose/Objective(s)</h3> Deep inhalation breath hold (DIBH) treatment allows for greater sparing of healthy tissue by minimizing target motion due to respiration. However, the breath hold level achieved during simulation and throughout treatment is not perfectly reproducible. DIBH techniques such as spirometry define an allowed variation in the nominal breath hold level to facilitate treatment. This variation represents an uncertainty which must be incorporated into the robust evaluation which is essential in proton therapy treatment planning. The aim of this study is to evaluate the dosimetric impact of this uncertainty for DIBH patients treated with proton therapy using a spirometry system with visual feedback and to determine the ideal clinical workflow to ensure robustness. <h3>Materials/Methods</h3> A dedicated workflow involving simulation, treatment planning and quality assurance was developed and implemented in our clinic to assess the potential dosimetric impact of this uncertainty. The workflow involved a multi-scan simulation procedure in which patients were simulated under their nominal breath hold level and two additional breath hold levels at ± 100 mL tidal lung volume with respect to the nominal. This variation was chosen as it represents twice the allowed variation during treatment in order to be conservative. The additional scans were used to assess motion near the target and to determine the best techniques to be used during plan optimization to ensure robustness. In particular a 5 mm motion threshold was used by physics to recommend the use of simultaneous optimization across all three image sets. The final treatment plan was forward calculated on the additional image sets to guarantee robustness. Patient data, including on-treatment imaging and verification CT scans (QA-CT), were analyzed to assess plan robustness for 30 patients treated under this workflow over two years. <h3>Results</h3> Out of 30 DIBH patients treated under this workflow the simultaneous optimization tool was recommended in three cases but ultimately not utilized in planning at MD/dosimetry discretion balancing dose to OARs and robustness. All thirty patients passed the robust evaluation procedure and there were no cases for which QA-CT indicated a need to revise a treatment plan due to a variation in the breath hold level. <h3>Conclusion</h3> Our initial experience indicates that in proton therapy utilizing spirometry based DIBH with visual feedback the uncertainty associated with the variation in breath hold level does not have a significant dosimetric impact on plan robustness. Given these results, the decision was made to reduce the workload and simplify the workflow by eliminating the additional scans and utilizing a single breath hold level during simulation.

Application of Wearable Sensors in the Treatment of Cervical Spondylosis Radiculopathy with Acupuncture.

Research shows that cervical spondylosis radiculopathy (CSR) is the most common type of cervical spondylosis in clinic, and Chinese medicine treatment has obvious advantages, among which acupuncture therapy has received increasing attention. CSR has the characteristics of high incidence, long treatment time, and easy recurrence after treatment. In order to meet the different needs of different patients, this paper uses wearable sensors to collect patient dynamic data, extracts the action features of cervical spondylosis to design a scoring system, analyzes the input feature scores through a convolutional neural network (CNN) model, and then outputs personalized acupuncture treatment plan. The development status of wearable sensors at home and abroad is introduced, and the modules and functions of the wearable sensors are designed. The CNN network is used as the network model for classification and recognition. The experimental results show that the CNN model used in this paper has a high classification accuracy, achieving an accuracy of up to 97%, and can help produce an effective treatment plan. In order to determine whether the treatment plan output by the model is effective, each group of data is handed over to two cervical spondylosis experts for scoring, and then the final treatment plan is determined from 10 acupuncture plans. In our experiments, 9 out of 10 plans generated by the CNN model were the same as generated by the experts, which shows the effectiveness of the model.

The Role of Orthodontic Treatment and Prosthetics during the Recovery Period after Surgical Treatment

The present paper considers the role of orthodontic treatment and prosthetics in the recovery period after surgical treatment of an injury to the maxillofacial area. Analyzing the sources within the framework of the research topic, the author cconcludes tthat surgical treatment of maxillofacial trauma and postoperative rehabilitation often requires an interdisciplinary approach, which makes it a difficult task. This is due to the fact that these injuries usually affect several structures of the oral cavity and face, including hard and soft tissues, often causing malocclusion. Thus, the clinical picture and the appropriate treatment strategy may vary greatly from one person to another. Therefore, before drawing up a final treatment plan, a thorough and thoughtful multidisciplinary assessment of each patient is necessary.

Abstract LB010: SMMART Program: A multi-omics tumor board with a focus on breast cancer

Abstract Many of the current approaches to personalized medicine rely on sequencing DNA to identify actionable mutations. However, growing evidence suggests that a multi-omic approach to more broadly assess biology is needed to improve patient outcomes. We have implemented a workflow for tissue acquisition, multi-omic clinical testing, and correlated computational biology analysis, within the Serial Measurements of Molecular and Architectural Responses to Therapy (SMMART) Program (Mitri et al, J Transl Med 2018). We report biopsy metrics, CLIA analytics utilized, the operation of a multi-omics tumor board, and clinical outcomes in metastatic breast cancer patients. A detailed clinical history of each patient was obtained, including demographics, tumor type, treatment and response to prior therapies, imaging, and blood tumor biomarkers. A comprehensive set of clinical assays was performed on newly obtained tumor biopsies, including immunohistochemistry (ER, PR, HER2, AR, BCL-2, and PD-L1), a targeted next-generation sequencing panel covering 225 genes (GeneTrails® Comprehensive Solid Tumor Panel), whole exome sequencing (Tempus xE), whole transcriptomic sequencing (Illumina TruSeq RNA exome), and a multiplex protein analysis of 22 key cancer proteins and phosphoproteins on the Nanostring platform (NanoString Vantage 3D™ Solid Tumor Panel). The integrated clinical and analytical information was made available to the multidisciplinary SMMART Clinical Tumor Board that provided treatment recommendations; the final treatment plan was at the discretion of the treating physician. Between 1/1/2017-1/1/2020, 53 breast cancer patients were consented. Seven screen-failed due to a lack of sites amenable to biopsy and 8 were actively co-consented to other clinical trials. The remaining 38 patients are included in this preliminary report. A total of 63 biopsies were collected from lymph node, liver, bone, soft tissue, lung, skin, breast, and brain. Serial biopsies (≥2) were obtained for 15 patients. Analytics were generated in 93.7% of biopsies. Tumor boards were held for 15 patients (17 total sessions). The experience and information gathered thus far have yielded the following unique cases: (1) single patient analysis of omics, imaging, and response over 42 months, (2) identification of an ERBB3 mutation with downstream pathway activation that responded to HER2-targeted therapy, and (3) clinically significant variation in hormonal and HER2 receptor status over time. We will provide an analysis across the 38 patients of treatment outcomes, analytics information content, biological changes observed through serial biopsies, and tumor board interventions. We demonstrate the feasibility of implementing a deep, real-time analytics platform for metastatic breast cancer patients that can provide new insight into therapeutic opportunities. The observed clinical responses support further use and investigation of this approach. Citation Format: Ben L. Kong, Brett E. Johnson, Jamie M. Keck, Souraya Mitri, Patrick Leyshock, Jayne M. Stommel, Kiara Siex, Marlana Klinger, Christina L. Zheng, Rochelle Williams-Belizaire, Shannon McWeeney, Jeremy Goecks, Annette Kolodzie, Alexander R. Guimaraes, George V. Thomas, Christopher L. Corless, Zahi I. Mitri, Joe W. Gray, Gordon B. Mills, Raymond C. Bergan. SMMART Program: A multi-omics tumor board with a focus on breast cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr LB010.