3D printing is an adaptable technology that is playing an increasing role in medical practice and innovation.Although 3D printing is gaining recognition as an effective clinical and educational tool in procedurally-intensive specialties, it has a nascent role in radiation oncology. The goal of this investigation, therefore, is to clarify the extent to which 3D printing applications are currently being used in radiation oncology through a systematic review of the literature. A search protocol was defined according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, using the Population, Intervention, Control, Outcomes (PICO) framework for identification of eligible studies. Two independent reviewers searched PubMed with combinations of predetermined Medical Subject Headings and generic search terms. Any study using 3D printing technology in relation to the delivery or study of radiotherapy was included. In-press articles from radiation oncology and medical physics journals were searched. Article references were examined for identification of any remaining publications. Included articles were evaluated using parameters of interest including: year/country of publication, experimental design, sample size for clinical studies, radiation oncology topic, reported outcomes, and implementation barriers or safety concerns. 103 publications met inclusion criteria. The most commonly described 3D printing applications included quality assurance phantoms (26%), brachytherapy applicators (20%), bolus (17%), preclinical animal irradiation (10%), compensators (7%), and immobilization devices (5%). Most studies were pre-clinical feasibility studies (63%), with few clinical investigations such as case reports or series (13%) or cohort studies (11%). The most common applications evaluated in clinical studies included brachytherapy applicators (42%) and bolus (27%). Furthermore, sample sizes for clinical investigations were small (median 10, range 1-42). A minority of articles described basic or translational research (11%) and workflow or cost evaluation studies (3%). Number of articles increased yearly, as follows (P<0.0001): 2012 (1%), 2013 (0), 2014 (6%), 2015 (14%), 2016 (18%), 2017 (27%), 2018 (31%). While outcomes were varied, the majority of studies reported successful implementation of accurate and cost-effective 3D printing methods. 3D printing is rapidly growing in radiation oncology and has been implemented effectively in a diverse array of applications. Although the number of 3D printing publications has steadily risen, the majority of current reports are pre-clinical in nature and the few clinical studies that do exist report on small sample sizes. Further investigation describing the clinical application and evaluation of developed 3D printing technologies in larger cohorts is warranted.
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