Three-dimensional Treatment Planning Research Articles

Effect of breathing phase number on the 4D robust optimization for pancreatic cancer intensity modulated proton therapy

PurposeRespiratory movement, as one of the main challenges in proton therapy for pancreatic cancer patients, could not only lead to harm to normal tissues but also lead to failure of the tumor control, resulting in irreversible consequences. Including respiratory movements into the plan optimization, i.e. 4D robust optimization, may mitigate the interplay effect. However, 4D robust optimization considering images of all breathing phases is time-consuming and less efficient. This work aims to investigate the effect of the breathing phase number on the 4D robust optimization for pancreatic cancer intensity modulated proton therapy (IMPT) by examining plan quality and computational efficiency.MethodsA total of 15 pancreatic cancer patients were retrospectively analyzed. In this study, both anterior-fields and posterior-fields plans were created for each patient. For each plan, six four-dimensional (4D) robust treatment planning strategies with different numbers of respiratory phases and one three-dimensional (3D) treatment plan were created. Optimization of the plans were performed on all ten phases (10phase plan), two extreme phases (2phase plan), two extreme phases plus an intermediate state (3phase plan), two extreme phases plus the 3D CT (3Aphase plan), six phases during the exhalation stage (6Exphase plan), six phases during the inhalation stage (6Inphase plan) and 3D Computed Tomography (CT) scan image (3D plan), respectively. 4D dynamic dose (4DDD) was then calculated to access the interplay effect by considering respiratory motion and dynamic beam delivery. Plan quality and dosimetric parameters for the target and organs at risk (OARs) were then analyzed.ResultsCompared to the 4D plans, 3D plan performed terribly in terms of target coverage and organs at risk. Target dose in anterior-fields plan varied slightly among all six 4D treatment planning strategies. Both the 6Exphase and 6Inphase plans demonstrated performance that was comparable to the 10phase plan in target coverage, outperforming the other five plans for anterior-fields plan. It’s basically the same for the posterior-fields plan. The six strategies showed similar OARs sparing effect for both anterior-fields and posterior-fields plan. Compared with the 10phase plan, the average decline rates of the optimization time of the six plans of 2phase, 3phase, 3Aphase, 6Exphase, 6Inphase, and 3D were 73.26 ± 6.54% vs. 74.48 ± 6.63%, 65.80 ± 7.89% vs. 65.81 ± 9.58%, 54.67 ± 11.52% vs. 65.75 ± 9.58%, 42.14 ± 13.57% vs. 39.63 ± 16.93%, 37.72 ± 11.70% vs. 40.79 ± 13.62% and 75.52 ± 8.21% vs. 80.67 ± 5.62%, respectively (anterior vs. posterior). With the decrease of the number of phases selected for optimization, the decline rates increased, while the other dosimetry parameters generally showed a deterioration trend.ConclusionIn this study, a comprehensive evaluation of six 4D robust treatment planning strategies and one 3D treatment planning strategy for pancreatic cancer patients receiving IMPT was performed. The results showed that six 4D robust optimization strategies were comparable in common posterior field therapy. 2phase and 3phase (including 3Aphase) treatment planning strategies could replace the 10phase treatment planning strategy. It should be noted that patients with large motion amplitudes should receive special attention. The dosimetric performance of the 6Exphase and 6Inphase plans closely aligned with that of the 10phase plan in anterior fields. These plans offered a feasible alternative to 10phase treatment planning strategy by reducing optimization time while maintaining dose coverage of the target and protection of OARs. This research provides guidelines to reduce optimization time and improve clinical efficiency for pancreatic cancer IMPT.

125I seed implantation for lymph node metastasis from radioactive iodine-refractory differentiated thyroid carcinoma: a study on short-term efficacy and dosimetry.

To investigate the feasibility and evaluate the safety and effectiveness of Computed Tomography (CT) guided125I radioactive particle implantation for treating lymph node metastases in radioiodine-refractory differentiated thyroid cancer (RAIR-DTC). To verify the accuracy of the computerized three-dimensional treatment planning system (TPS) in treating lymph node metastasis using125I particle implantation at the dosimetric level. A retrospective analysis was conducted on 42 patients with RAIR-DTC and lymph node metastases who were admitted to the General Hospital of the Northern Theater Command between December 2016 and January 2019. During this analysis, physicians utilized preoperative CT images to design an intraoperative plan using TPS. The dosimetric parameters of the postoperative plan were then compared to the preoperative plan. Additionally, this study examined the changes in tumor size and tumor-related marker Thyroglobulin (Tg) values in patients at 2, 6, and 12 months after the operation. The number of125I radioactive particles implanted in 42 patients was 226, with an average of 14.5 (range 2.0-30.0) particles implanted per lesion. The local remission rates were 97.62% (41/42), 88.10% (37/42), and 85.71% (36/42) at 2, 6, and 12 months postoperatively, respectively. The volume of the lesions was (4.44 ± 1.57) cm3, (4.20 ± 1.70) cm3, and (4.23 ± 1.77) cm3at 2, 6, and 12 months after treatment, respectively, which significantly decreased from the preoperative baseline level of (6.87 ± 1.67) cm3(t-values: 9.466, 9.923, 7.566, all P<0.05). The Tg levels were 15.95 (5.45, 73.93) μg/L, 8.90 (2.20, 39.21) μg/L, and 6.00 (1.93, 14.18) μg/L at 2, 6, and 12 months after treatment, respectively, which were significantly lower than the preoperative baseline levels of 53.50 (20.94, 222.92) μg/L (Z values: -5.258, -5.009, -4.987, all P < 0.001). Postoperatively, Delivered to 90% of the GTV(D90) was slightly lower than the prescribed dose in 95.23% (40/42) of patients, but the difference was not statistically significant [(12,378.8 ± 3,182.0), (12,497.8 ± 1,686.4) cGy; t=0.251, P>0.05], and postoperative dose parameters delivered to 100% of the gross tumor volume (GTV)(D100) (6,881.5 ± 1,381.8) cGy, the volume percentages of GTV receiving 150% of the prescribed dose(V150) (58.5 ± 18.40)%) were lower than the preoperative plan D100 (8,085.8 ± 2,330.0) cGy, V150 (66.5 ± 17.70)%; t-value=8.913 and 3.032, both P<0.05; the remaining indicators were not significantly different from the preoperative plan (the differences in the number of implanted particles, Planning Target Volume(PTV), the volume percentages of GTV receiving 100% of the prescribed dose(V100), Homogeneity Index(HI)were not statistically significant (t/Z = -0.593, -1.604, 1.493, -0.663, all P>0.05). Referring to the TPS preoperative plan, the125I particle implantation therapy for RAIR-DTC lymph node metastasis can achieve the expected dose distribution, ensuring precise short-term local tumor control efficacy.

Limitation of Aligners and How to Overcome Them

Aligners are a popular choice for many people seeking Orthodontic treatment due to their aesthetic appeal and convenience. They offer a more discreet alternative to traditional braces, as they are difficult to notice when worn. Along with that it provides an excellent substitute in the era of three-dimensional treatment planning. Clear aligners gradually exert gentle forces on the teeth, moving them incrementally until they reach the desired alignment. The aligner trays are designed to apply pressure to specific areas of your teeth, gradually shifting them into the correct position. The treatment process continues until all the teeth are properly aligned and bite is optimized. Earlier clear aligner treatment was considered to be utilized for the simpler cases, but with advancements it is proved that aligners can be one of the many possibilities for extraction cases, open bite, deep bite, interceptive and even for hybrid approaches. However, aligners may not be suitable for all Orthodontic treatment modalities, especially those requiring significant jaw alignment or complex tooth movements. This review focuses on the limitations and constraints of the type of movements provided by the clear aligners. Furthermore, this will assess the possibilities to overcome these obstacles for better performances in the near future.

Creation of Dimicleft radiological cleft phantom skulls using reversed virtual planning technique.

The aim of this technical report was to develop customized pediatric phantoms for cone-beam computed tomography (CBCT)-related research in cleft patients. Six human pediatric skulls (age: 5-10 years) were recruited. A cone-beam computed tomography (CBCT) scan was taken for each skull, followed by virtual modeling through the process of segmentation. An artificial cleft was designed and printed to be applied onto the skull for the creation of an artificial cleft. The skulls were covered with non-radiopaque tape and immersed in melted Mix-D soft tissue equivalent material. The resulting phantoms covered with Mix-D were assessed radiologically by two expert radiologists. These phantoms were referred to as Dimicleft pediatric skull phantoms. Dimicleft phantoms were able to appropriately mimic in vivo circumstances. No gaps existed between Mix-D and bony tissue. Virtual planning allowed the optimal designing of an artificial cleft onto the phantom. The artificially created cleft was suitable to determine the size, location, and extent of the cleft. Dimicleft phantoms could act as a viable alternative to other commercially available options for assessing image quality and optimizing CBCT protocols in cleft patients for diagnostics and three-dimensional treatment planning.

Deep inspiration breath-hold radiation therapy in left-sided breast cancer patients: a single-institution retrospective dosimetric analysis of organs at risk doses

BackgroundRadiotherapy can induce cardiac injury in left-sided breast cancer cases. Cardiac-sparing irradiation using the deep inspiration breath-hold (DIBH) technique can achieve substantial dose reduction to vulnerable cardiac substructures compared with free breathing (FB). This study evaluated the dosimetric differences between both techniques at a single institution.MethodsFrom 2017 to 2019, 130 patients with left-sided breast cancer underwent breast-conserving surgery (BCS; n = 121, 93.1%) or mastectomy (ME; n = 9, 6.9%) along with axillary lymph node staging (n = 105, 80.8%), followed by adjuvant irradiation in DIBH technique; adjuvant systemic therapy was included if applicable. 106 (81.5%) patients received conventional and 24 (18.5%) hypofractionated irradiation. Additionally, 12 patients received regional nodal irradiation. Computed tomography (CT) scans in FB and DIBH position were performed for all patients. Intrafractional 3D position monitoring of the patient surface in deep inspiration and breath gating was performed using Sentinel and Catalyst HD 3D surface scanning systems (C-RAD, Catalyst, C‑RAD AB, Uppsala, Sweden). Individual coaching and determination of breathing amplitude during the radiation planning CT was performed. Three-dimensional treatment planning was performed using standard tangential treatment portals (6 or 18 MV). The delineation of cardiac structures and both lungs was done in both the FB and the DIBH scan.ResultsAll dosimetric parameters for cardiac structures were significantly reduced (p < 0.01 for all). The mean heart dose (Dmean) in the DIBH group was 1.3 Gy (range 0.5–3.6) vs. 2.2 Gy (range 0.9–8.8) in the FB group (p < 0.001). The Dmean for the left ventricle (LV) in DIBH was 1.5 Gy (range 0.6–4.5), as compared to 2.8 Gy (1.1–9.5) with FB (p < 0.001). The parameters for LV (V10 Gy, V15 Gy, V20 Gy, V23 Gy, V25 Gy, V30 Gy) were reduced by about 100% (p < 0.001). The LAD Dmean in the DIBH group was 4.1 Gy (range 1.2–33.3) and 14.3 Gy (range 2.4–37.5) in the FB group (p < 0.001). The median values for LAD such as V15 Gy, V20 Gy, V25 Gy, V30 Gy, and V40 Gy decreased by roughly 100% (p < 0.001). An increasing volume of left lung in the DIBH position resulted in dose sparing of cardiac structures.ConclusionFor all ascertained dosimetric parameters, a significant dose reduction could be achieved in DIBH technique.

Incidental irradiation of the regional lymph nodes during deep inspiration breath-hold radiation therapy in left-sided breast cancer patients: a dosimetric analysis

BackgroundRadiotherapy using the deep inspiration breath-hold (DIBH) technique compared with free breathing (FB) can achieve substantial reduction of heart and lung doses in left-sided breast cancer cases. The anatomical organ movement in deep inspiration also cause unintended exposure of locoregional lymph nodes to the irradiation field.MethodsFrom 2017–2020, 148 patients with left-sided breast cancer underwent breast conserving surgery (BCS) or mastectomy (ME) with axillary lymph node staging, followed by adjuvant irradiation in DIBH technique. Neoadjuvant or adjuvant systemic therapy was administered depending on hormone receptor and HER2-status.CT scans in FB and DIBH position with individual coaching and determination of the breathing amplitude during the radiation planning CT were performed for all patients. Intrafractional 3D position monitoring of the patient surface in deep inspiration and gating was performed using Sentinel and Catalyst HD 3D surface scanning systems (C-RAD, Catalyst, C-RAD AB, Uppsala, Sweden). Three-dimensional treatment planning was performed using standard tangential treatment portals (6 or 18 MV). The delineation of ipsilateral locoregional lymph nodes was done on the FB and the DIBH CT-scan according to the RTOG recommendations.ResultsThe mean doses (Dmean) in axillary lymph node (AL) level I, II and III in DIBH were 32.28 Gy (range 2.87–51.7), 20.1 Gy (range 0.44–53.84) and 3.84 Gy (range 0.25–39.23) vs. 34.93 Gy (range 10.52–50.40), 16.40 Gy (range 0.38–52.40) and 3.06 Gy (range 0.21–40.48) in FB (p < 0.0001). Accordingly, in DIBH the Dmean for AL level I were reduced by 7.59%, whereas for AL level II and III increased by 22.56% and 25.49%, respectively.The Dmean for the supraclavicular lymph nodes (SC) in DIBH was 0.82 Gy (range 0.23–4.11), as compared to 0.84 Gy (range 0.22–10.80) with FB (p = 0.002). This results in a mean dose reduction of 2.38% in DIBH.The Dmean for internal mammary lymph nodes (IM) was 12.77 Gy (range 1.45–39.09) in DIBH vs. 11.17 Gy (range 1.34–44.24) in FB (p = 0.005). This yields a mean dose increase of 14.32% in DIBH.ConclusionsThe DIBH technique may result in changes in the incidental dose exposure of regional lymph node areas.

Treatment Planning for Cardiac Radioablation: Multicenter Multiplatform Benchmarking for the RAdiosurgery for VENtricular TAchycardia (RAVENTA) Trial

Cardiac radioablation is a novel treatment option for patients with refractory ventricular tachycardia unsuitable for catheter ablation. The quality of treatment planning depends on dose specifications, platform capabilities, and experience of the treating staff. To harmonize the treatment planning, benchmarking of this process is necessary for multicenter clinical studies such as the RAdiosurgery for VENtricular TAchycardia trial. Planning computed tomography data and consensus structures from 3 patients were sent to 5 academic centers for independent plan development using a variety of platforms and techniques with the RAdiosurgery for VENtricular TAchycardia study protocol serving as guideline. Three-dimensional dose distributions and treatment plan details were collected and analyzed. In addition, an objective relative plan quality ranking system for ventricular tachycardia treatments was established. For each case, 3 coplanar volumetric modulated arc (VMAT) plans for C-arm linear accelerators (LINAC) and 3 noncoplanar treatment plans for robotic arm LINAC were generated. All plans were suitable for clinical applications with minor deviations from study guidelines in most centers. Eleven of 18 treatment plans showed maximal one minor deviation each for target and cardiac substructures. However, dose-volume histograms showed substantial differences: in one case, the planning target volume ≥30 Gy ranged from 0.0% to 79.9% and the ramus interventricularis anterior V14Gy ranged from 4.0% to 45.4%. Overall, the VMAT plans had steeper dose gradients in the high-dose region, while the plans for the robotic arm LINAC had smaller low-dose regions. Thereby, VMAT plans required only about half as many monitor units, resulting in shorter delivery times, possibly an important factor in treatment outcome. Cardiac radioablation is feasible with robotic arm and C-arm LINAC systems with comparable plan quality. Although cross-center training and best practice guidelines have been provided, further recommendations, especially for cardiac substructures, and ranking of dose guidelines will be helpful to optimize cardiac radioablation outcomes.

Study on esophageal cancer radiotherapy dosimetry and position verification for volumetric modulated arc therapy

BackgroundThis study analyzed the respective advantages and disadvantages by comparing volumetric modulated arc therapy (VMAT) and intensity modulated radiotherapy (IMRT) on the dose distribution and position verification distribution characteristics in esophageal cancer radiotherapy, in order to provide the reference for the clinical radiotherapy technology optimization of esophageal cancer. MethodsA total of 56 cases of patients with esophageal cancer were selected and applied to the Pinnacle three-dimensional radiation treatment planning system (TPS), in order to design a VMAT plan and IMRT plan under the guidance of image-guided radiotherapy (IGRT). The dosimetry and position verification difference were compared between the two groups. ResultsRevealed that the target dose distribution of the VMAT plan and IMRT plan meets the requirements in clinical dosimetry for all 56 patients in this study. Under the premise of similar target coverage, the conformal index (CI) of the VMAT plan, homogeneity index (HI), target volume, BODY-PTV radiated volume and spinal cord Dmax, bilateral lung V5, V20 and mean lung dose (MLD), monitor unit (MU) and treatment time (TT), as well as position verification and others, were obviously superior to those in the IMRT plan; and the difference was statistically significant. ConclusionCBCT guided VMAT is a potential effective treatment for esophageal cancer and may be more effective and safer than IMRT.

Development of Organ-Preserving Radiation Therapy in Gastric Marginal Zone Lymphoma

Simple SummaryGastric marginal zone lymphoma of the stomach is a rare cancer type primarily treated with oral proton pump inhibitors. If the disease does not respond to this, radiation is the treatment of choice. This review presents the development of radiation therapy over the last decades. Earlier, the stomach was surgically removed and irradiation was performed using large-field techniques and high doses of radiation. Currently, the standard treatment is the use of small-volume radiation therapy (with few side effects) with the preservation of the stomach, which provides excellent outcomes. In addition, this paper provides an outlook on current studies and possible future developments.Gastric marginal zone lymphoma (gMZL) of mucosa-associated lymphoid tissue (MALT) may persist even after H. pylori eradication, or it can be primarily Helicobacter pylori (H. pylori) independent. For patients without the successful eradication of lymphoma, or with progressive disease, treatment options have historically included partial or total gastrectomy. Presently, in these instances, curative radiation therapy (RT) is the current standard of care. This review emphasizes the historically changing role of radiation therapy in gMZL, progressing from large-volume RT without surgery, to localized RT, on its own, as a curative organ-preserving treatment. This overview shows the substantial progress in radiation therapy during the recent two to three decades, from high-dose, large-field techniques to low-dose, localized target volumes based on advanced imaging, three-dimensional treatment planning, and advanced treatment delivery techniques. RT has evolved from very large extended field techniques (EF) with prophylactic treatment of the whole abdomen and the supradiaphragmatic lymph nodes, applying doses between 30 and 50 Gy, to involved-field RT (IF), to the current internationally recommended involved site radiation therapy (ISRT) with a radiation dose of 24–30 Gy in gMZL. Stage-adapted RT is a highly effective and safe treatment with excellent overall survival rates and very rare acute or late treatment-related toxicities, as shown not only in retrospective studies, but also in large prospective multicenter studies, such as those conducted by the German Study Group on Gastrointestinal Lymphoma (DSGL). Further de-escalation of the radiation treatments with low-dose 20 Gy, as well as ultra-low-dose 4 Gy radiation therapy, is under investigation within ongoing prospective clinical trials of the International Lymphoma Radiation Oncology Group (ILROG) and of the German Lymphoma Alliance (GLA).

3D Dosimetry Based on LiMgPO4 OSL Silicone Foils: Facilitating the Verification of Eye-Ball Cancer Proton Radiotherapy.

A direct verification of the three-dimensional (3D) proton clinical treatment plan prepared for tumor in the eyeball, using the Eclipse Ocular Proton Planning system (by Varian Medical Systems), has been presented. To achieve this, a prototype of the innovative two-dimensional (2D) circular silicone foils, made of a polymer with the embedded optically stimulated luminescence (OSL) material in powder form (LiMgPO4), and a self-developed optical imaging system, consisting of an illuminating light source and a high-sensitive CCD camera has been applied. A specially designed lifelike eyeball phantom has been used, constructed from 40 flat sheet LMP-based silicone foils stacked and placed together behind a spherical phantom made by polystyrene, all to reflect the curvature of the real eyeball. Two-dimensional OSL signals were captured and further analyzed from each single silicone foil after irradiation using a dedicated patient collimator and a 58.8 MeV modulated proton beam. The reconstructed 3D proton depth dose distribution matches very well with the clinical treatment plan, allowing for the consideration of the new OSL system for further 3D dosimetry applications within the proton radiotherapy area.

Tumor Control Probability (TCP) and Normal Tissue Complication Probability (NTCP) in Mono and Dual-isocentric Techniques of Breast Cancer Radiation Therapy

Background: Nowadays, radiation therapy plays an important role in the treatment of breast cancer. The important point is the optimal control of the tumor along with the protection of organs at risk. This study aims to investigate and compare the radiobiological factors of the tumor and organs at risk in two different radiation therapy techniques of breast cancer.Methods: Ten left-sided breast cancer patients with breast-conservative surgery were selected for this study. Three-dimensional treatment planning was performed using CT scan images of the patients using PCRT 3D software. Two different tangential external beam techniques were compared: first, dual-isocentric technique (DIT) with two isocentre, one on the breast tissue, and the other one on the supraclavicular lymph nodes and second, a mono-isocentric technique (MIT) with one isocentre at the intersection of the tangential and the supraclavicular field. The total prescribed dose was 5000 cGy per 25 fractions. Dose-volume histograms (DVHs), Tumor control probability (TCP), and normal tissue complication probability (NTCP) curves were used to compare the dosimetric and radiobiological parameters of the tissues in the prementioned techniques. Results: The results showed that the maximum doses in planning target volume (PTV) with mean values of 109% and 110% in the SI and DIT were not significantly different in both techniques and that they were indeed at the optimum level based on the RTOG 1005 protocol. The dose homogeneity index in MMIT was more than that in DIT, while the conformity index and the mean TCP did not show a significant difference in the two techniques. Furthermore, minimum, mean, and maximum dose in the lung and the probability of pneumonitis decreased in MIT. On the other hand, the maximum dose, the dose of 33%, 66%, and 100% of the heart, and the probability of pericarditis in MIT were lower than the figure in DIT. Conclusion: Due to the absence of hot spots at the intersection of tangential and supraclavicular fields and the reduction of mechanical movements of the coach and collimator in MIT, the superiority of this method was confirmed.

Independent verification of treatment planning system calculations

Abstract Purpose According to the available international recommendations, at least one independent verification of the calculations of number of monitor unit (MU) is required for every patient treated by teleradiotherapy. The aim of this study was to estimate the differences of dose distributions calculated with two treatment planning systems: Eclipse (Varian) and Oncentra MasterPlan (Elekta). Materials and methods The analysis was performed for 280 three-dimensional conformal radiotherapy treatment (3D-CRT) plans with photon beams from Varian accelerators: CL 600C/D X6 MV (109 plans), CL 2300C/D X6 MV (43 plans), and CL 2300C/D X15 MV (128 plans). The mean doses in the planning target volume (PTV) and doses at the isocenter point obtained with Eclipse and Oncentra MasterPlan (OMP) were compared with Wilcoxon matched-pairs signed rank test. Additionally, the treatment planning system (TPS) calculations were compared with dosimetric measurements performed in the inhomogeneous phantom. Results Data were analysed for 6 MV plans and for 15 MV plans separately, independently of the treatment machine. The dose values calculated in Eclipse were significantly (p &lt;0.001) higher compared to calculations of OMP system. The average difference of the mean dose to PTV was (1.4 ± 1.0)% for X6 MV and (2.5 ± 0.6)% for X15 MV. Average dose disparities at the isocenter point were (1.3 ± 1.9)% and (2.1 ± 1.0)% for X6 MV and X15 MV beams, respectively. The largest differences were observed in lungs, air cavities, and bone structures. Moreover the variation in dosimetric measurements was less as compared to Eclipse calculations. Conclusions OMP calculations were introduced as the independent MU verification tool with the first action level range equal to 3.5%.

Clinical Evaluation of a Three-Dimensional Internal Dosimetry Technique for Liver Radioembolization with 90Y Microspheres Using Dose Voxel Kernels.

Background: The purpose of this study was to develop a rapid, reliable, and efficient tool for three-dimensional (3D) dosimetry treatment planning and post-treatment evaluation of liver radioembolization with 90Y microspheres, using tissue-specific dose voxel kernels (DVKs) that can be used in everyday clinical practice. Materials and Methods: Two tissue-specific DVKs for 90Y were calculated through Monte Carlo (MC) simulations. DVKs for the liver and lungs were generated, and the dose distribution was compared with direct MC simulations. A method was developed to produce a 3D dose map by convolving the calculated DVKs with the activity biodistribution derived from clinical single-photon emission computed tomography (SPECT) or positron emission tomography (PET) images. Image registration for the SPECT or PET images with the corresponding computed tomography scans was performed before dosimetry calculation. The authors first compared the DVK convolution dosimetry with a direct full MC simulation on an XCAT anthropomorphic phantom. They then tested it in 25 individual clinical cases of patients who underwent 90Y therapy. All MC simulations were carried out using the GATE MC toolkit. Results: Comparison of the measured absorbed dose using tissue-specific DVKs and direct MC simulation on 25 patients revealed a mean difference of 1.07% ± 1.43% for the liver and 1.03% ± 1.21% for the tumor tissue, respectively. The largest difference between DVK convolution and full MC dosimetry was observed for the lung tissue (10.16% ± 1.20%). The DVK statistical uncertainty was <0.75% for both media. Conclusions: This semiautomatic algorithm is capable of performing rapid, accurate, and efficient 3D dosimetry. The proposed method considers tissue and activity heterogeneity using tissue-specific DVKs. Furthermore, this method provides results in <1 min, making it suitable for everyday clinical practice.

Dosimetric Evaluation of Intensity Modulated Radiotherapy and Three-Dimensional Conformal Radiotherapy Treatment Plans for Prostate Cance

Dosimetric Evaluation of Intensity Modulated Radiotherapy and Three-Dimensional Conformal Radiotherapy Treatment Plans for Prostate Cance

An Inverse Dose Optimization Algorithm for Three-Dimensional Brachytherapy.

PurposeTo investigate an implementation method and the results of an inverse dose optimization algorithm, Gradient Based Planning Optimization (GBPO), for three-dimensional brachytherapy.MethodsThe GBPO used a quadratic objective function, and a dwell time modulation item was added to the objective function to restrict the dwell time variance. We retrospectively studied 4 cervical cancer patients using different applicators and 15 cervical cancer patients using the Fletcher applicator. We assessed the plan quality of GBPO by isodose lines for the patients using different applicators. For the 15 patients using the Fletcher applicator, we utilized dose-volume histogram (DVH) parameters of HR-CTV (D100%, V150%) and organs at risk (OARs) (D0.1cc, D1cc, D2cc) to evaluate the difference between the GBPO plans and the IPSA (Inverse Planning Simulated Annealing) plans, as well as the GBPO plans and the Graphic plans.ResultsFor the 4 patients using different applicators, the dose distributions are conformable. For the 15 patients using the Fletcher applicator, when the dwell time modulation factor (DTMF) is less than 20, the dwell time deviation reduces quickly; however, after the DTMF increased to 100, the dwell time deviation has no remarkable change. The difference in dosimetric parameters between the GBPO plans and the IPSA plans is not statistically significant (P>0.05). The GBPO plans have a higher D100% (3.57 ± 0.36, 3.38 ± 0.34; P<0.01) and a lower V150% (55.73 ± 4.06, 57.75 ± 3.79; P<0.01) than those of the Graphic plans. The differences in other DVH parameters are negligible between the GBPO plans and the Graphic plans.ConclusionsThe GBPO plans have a comparable quality as the IPSA plans and the Graphic plans for the studied cervical cancer cases. The GBPO algorithm could be integrated into a three-dimensional brachytherapy treatment planning system after studying more sites.

A fast quality assurance method for three-dimensional Afterloading treatment plan

Objective To study the relationship between tumor siza, aource intensita, arescription dose and source dwell time in the after-loading treatment plaa, and to establish a method that can be used for rapid quality control of after-loading plans. Methods The all of gynecological cancer patients treated in this hospital were selected: 84 cases of all three tubes of Fletcher applicator, 58 cases of uterine alone and 39 cases of vaginal applicator. Each patient was scanned with CT before treatment. Contouring the target and organs at risa, ahe treatment plan was optimized using IPSA. Record the source strengta, arescription dosa, aource dwell tima, and tumor volume of the prescribed dose for each case. Calculate CI values and Rv. The k-value analyzes the CI distribution characteristics and the correlation with the Rv value. In addition, 46 cases of gynecologic tumor patients were used to verify the method. Results The fitting index of the after-loading scheme of the three applicators showed a normal distribution. The mean value of the Fletcher applicator CI was 0.720±0.067, the k value was 1 394, Rvalue was 0.894. The mean value of the uterine alone CI was 0.697±0.076, the k value was 1 428, R=0.940, the mean value of the vaginal applicator CI was 0.742±0.067, the k value was 1 362, and R=0.909. Conclusions Using this methoa, at can quickly assess whether the planned target voluma, aadiation source intensita, arescription dose and treatment time matca, and find the cause of deviation based on the feedback results to ensure that the after-loading treatment plan can be quickla, accuratela, and efficiently implemented according to clinical requirements. Key words: Brachytherapy; Simulated annealing reverse plan; Rapid quality control; Three-dimensional loading

The Financial Impact of Fractionation Scheme and Treatment Planning Method for Rectal Cancer in the United States

BackgroundPreoperative long-course chemoradiotherapy (CRT) and short-course radiotherapy (SCR) for locally advanced rectal cancer (LARC) were found to have equivalent outcomes in 3 randomized trials. SCR has not been widely adopted in the United States (US). Three-dimensional (3D) treatment planning is standard, whereas intensity-modulated radiotherapy (IMRT) is controversial. In this study, we assessed the economic impact of fractionation scheme and planning method for payers in the US. Materials and MethodsWe performed a population-based analysis of the total cost of radiotherapy for LARC in the US annually. The national annual target population was calculated using the Surveillance, Epidemiology, and End Results database. Radiotherapy costs were based on billing codes and 2018 pricing by Medicare's Hospital Outpatient Prospective Payment System. ResultsWe estimate that 12,945 patients with LARC are treated with radiotherapy annually in the US. The cost of CRT with 3D or IMRT is US $15,882 and $23,745 per patient, respectively. With SCR, the cost with 3D or IMRT is $5,458 and $7,323 per patient, respectively. The use of SCR would lead to 53% to 77% annual savings of $106,168,871 to $232,105,727 compared with CRT. IMRT increases the total cost of treatment by 34% to 50%, and if adopted widely, would lead to an excess cost of $24,152,134 and $101,784,723 annually with SCR and CRT, respectively. ConclusionsSCR may have the potential to save approximately US $106 to t232 million annually in the US, likely without impacting outcomes. Lack of evidence showing benefit with costly IMRT should limit its use to clinical trials. It would be reasonable for public and private payers to consider which type of radiation is most suited to reimbursement.

Prospective International Pilot Study Evaluating the Efficacy of a Self-Guided Contouring Teaching Module With Integrated Feedback for Transitioning From 2D to 3D Treatment Planning.

PURPOSETransitioning from two-dimensional to three-dimensional treatment planning requires developing contouring skills. Contouring atlases are excellent resources, but they do not provide users active feedback. Developing countries may not have many radiation oncologists experienced in three-dimensional planning to provide training. We sought to develop a standardized self-guided educational module with integrated feedback to teach contouring skills.METHODS AND MATERIALSAll 18 oncology residents at Black Lion Hospital/Addis Ababa University in Ethiopia were trained to contour the level II lymph node station. Residents took a baseline pretest quiz, survey, and contouring evaluation. Residents then watched an instructional contouring lecture and performed three additional cases with integrated feedback by comparing their contours to gold-standard contours. Residents then took a post-training quiz, survey, and contouring evaluation. Paired t tests and analysis of variance were used for analysis.RESULTSBefore training, the average number of total cases ever contoured was 2.4 and the average number of head and neck cases contoured was 0.5. Comfort with contouring improved from being “not at all comfortable” to “quite comfortable” after the 3-hour training (P < .001). The standard deviation between the resident contours and gold standard improved from 72.6 cm3 (pretest) to 7.4 cm3 (post-test). The average percentage overlap with the gold-standard contours and Dice similarity coefficient improved with each case performed, from 27.7% and 0.26 (pretest) to 80.1% and 0.77 (post-test), respectively (P < .001). After training, 16 of 18 (88.9%) residents produced a Dice similarity coefficient greater than 0.7, the threshold generally accepted for excellent agreement.CONCLUSIONThis self-guided teaching module was an effective tool for developing level II lymph node contouring skills by providing active feedback and resulted in improved user confidence and accuracy compared with a gold standard. This module can be expanded to other disease sites and countries to further facilitate transitioning to three-dimensional treatment planning in developing countries.

Evaluation of variation of interfraction doses to organs at risk during brachytherapy of cervical cancer

BackgroundTwo-dimensional treatment planning using radiographs or simulator films was the standard in planning brachytherapy for patients with cervical cancer. Three-dimensional (3D) treatment planning has improved treatment efficacy. This retrospective study compares conventional and 3D treatment planning of brachytherapy in patients with cervical cancer and interfraction dose variation to bladder and rectum (D2cc). MethodsThe mean doses to bladder and rectum (D2cc) were computed by computed tomography (CT)–based planning during 100 sessions of intracavitary brachytherapy for carcinoma cervix with the same source configuration as generated for conventional planning, and these estimates were compared with the doses at International Commission on Radiation Units and measurements (ICRU) rectal, bladder points and point A. Interfraction variation of doses to bladder and rectum during various sessions was also analysed. ResultThe mean ICRU bladder dose and D2cc of the bladder for all patients was 3.7 Gy and 7.4 Gy, respectively (p < 0.001). The mean ICRU rectal dose from conventional plan was 4.3Gy and with CT planning, 4.45 Gy (p = 0.04). Interfraction dose variations for D2cc of the bladder were min −5.3 Gy and max 4.8 Gy and those of the rectum were min −1.8 Gy and max 1.72Gy. ConclusionDosimetric evaluation of conventional and 3D CT-based treatment planning for the same brachytherapy sessions demonstrated underestimation of ICRU bladder dose points (p < 0.001) and the rectal ICRU point dose and D2cc (p=0.04). The doses to organs at risk did not show a statistically significant variation between the fractions. However, large variation was noted between the interfractional maximum and minimum doses to bladder and rectum.

Ultrasound-guided percutaneous microwave ablation assisted by a three-dimensional visualization preoperative treatment planning system for larger adrenal metastasis (D ≥ 4 cm): Preliminary results.

The objective of this study is to assess the clinical effect and safety of ultrasound-guided percutaneous microwave ablation (US-PMWA) assisted by three-dimensional (3D) visualization operative treatment planning system in larger adrenal metastasis (LAM) (D ≥ 4 cm). From Dec 2011 to Dec 2017, 12 consecutive LAM patients with pathologically proven with a mean diameter of 5.2±1.3cm (range 4.1-7.6) were treated. Artificial ascites and thermal monitoring system as ancillary technique were used. The patients were followed up with imagings and complications were recorded. The median follow-up period was 31 months (ranged 6-52 m). All LAM achieved completely ablation according to the 3D planning preoperation. Complete ablation was achieved in 10 (10/12, 83.3%) patients by one session and 2 patients (2/12, 16.7%) by two sessions. Recurrence was detected at the treated site in 3 patients (3/12, 25.0%) at 5, 9, and 13 months after ablation and received another ablation. Progression of metastasis disease at extra-adrenal sites occurred in 9 patients (9/12, 75%). Seven (7/12, 58.3%) patients died during the follow-up period. Therefore, the 1-, 2-, and 3-year local tumor control rates were 83.3%, 75.0%, and 75.0%, and 1-, 2-, 3- and 4-year overall survival rates were 91.7%, 75.0%, 50.0%, and 41.7%, respectively. No severe complications related to ablation occurred, except 3 (3/12, 25%) patients developed hypertension during ablation. US-PMWA assisted by 3D visualization preoperative treatment planning system maybe a safe and efficient therapy for LAM, which could promote ablation precision, improve the clinical outcomes.