Robust Angle Selection in Particle Therapy

The popularity of particle radiotherapy has grown exponentially over recent years owing to the marked advantage of the depth–dose curve and its unique biological property. However, particle therapy is sensitive to changes in anatomical structure, and the dose distribution may deteriorate. In particle therapy, robust beam angle selection plays a crucial role in mitigating inter- and intrafractional variation, including daily patient setup uncertainties and tumor motion. With the development of a rotating gantry, angle optimization has gained increasing attention. Currently, several studies use the variation in the water equivalent thickness to quantify anatomical changes during treatment. This method seems helpful in determining better beam angles and improving the robustness of planning. Therefore, this review will discuss and summarize the robust beam angles at different tumor sites in particle radiotherapy.

The Rare Cases of Parotid Gland Arteriovenous Malformations

Arteriovenous malformation (AVM) results from errors in vascular development during embryogenesis; absent capillary beds lead to shunting directly from the arterial to venous circulation. Although it is common in the head and neck region, AVMs located in the parotid gland are quite rare. Here, we report two cases of arteriovenous malformation of the parotid gland that presented to our out-patient setup with swelling in the parotid region and were diagnosed as arteriovenous malformation on histopathological study after surgical resection.

Does kV Image Guidance for Bone Metastases Improve Pain Control?

Purpose/ObjectivesDespite its widespread availability, the use of kilovoltage (kV) image guidance is often related to factors such as perceived adequacy of clinical patient setup and individual practice patterns. We sought to determine whether kV image guidance in the treatment of painful bone metastases would improve therapeutic efficacy.Materials/MethodsUnder an Institutional Review Board approved protocol, hospital records of 164 patients having received radiation therapy to 257 individual painful osseous metastases were retrospectively reviewed. Marginal logistic regression analyses using the generalized estimating equation (GEE) approach were used to investigate potential associations between pain reduction and several patient, disease, and treatment related variables. Correlation of kV image guidance with pain reduction was analyzed by univariate and multivariate GEE logistic regression analysis.ResultsMedian time to pain reduction was 3 days (range 0~109 days) from the start of radiation therapy. Pain reduction ≥ 50% was noted in 196 (77%) metastatic lesions with 136 (53%) demonstrating complete pain relief. Patients with metastatic lesions from non-small cell lung cancer experienced less pain relief (p = 0.007). Disease extension outside of bone was a negative predictor for pain reduction (p = 0.02). On univariate and multivariate logistic regression, kV image guidance demonstrated a statistically significant correlation with improved pain control in cases involving treatment of the lower extremities (p = 0.03) and those with fewer treatment fractions (p = 0.01), particularly in the setting of extra-osseous disease extension (p = 0.003).ConclusionsKilovoltage image guidance in the treatment of painful bone metastases may offer greater pain control through improved patient setup, particularly for patients with tumors of the lower extremities, extraosseous disease extension, and fewer treatment fractions.

CBCT-Based Adaptive Assessment Workflow for Intensity Modulated Proton Therapy for Head and Neck Cancer

Purpose Anatomical changes and patient setup uncertainties during intensity modulated proton therapy (IMPT) of head and neck (HN) cancers demand frequent evaluation of delivered dose. This work investigated a cone-beam computed tomography (CBCT) and deformable image registration based therapy workflow to demonstrate the feasibility of proton dose calculation on synthetic computed tomography (sCT) for adaptive IMPT treatment of HN cancer. Materials and Methods Twenty-one patients with HN cancer were enrolled in this study, a retrospective institutional review board protocol. They had previously been treated with volumetric modulated arc therapy and had daily iterative CBCT. For each patient, robust optimization (RO) IMPT plans were generated using ±3 mm patient setup and ±3% proton range uncertainties. The sCTs were created and the weekly delivered dose was recalculated using an adaptive dose accumulation workflow in which the planning computed tomography (CT) was deformably registered to CBCTs and Hounsfield units transferred from the planning CT. Accumulated doses from ±3 mm/±3% RO-IMPT plans were evaluated using clinical dose-volume constraints for targets (clinical target volume, or CTV) and organs at risk. Results Evaluation of weekly recalculated dose on sCTs showed that most of the patient plans maintained target dose coverage. The primary CTV remained covered by the V95 > 95% (95% of the volume receiving more than 95% of the prescription dose) worst-case scenario for 84.5% of the weekly fractions. The oral cavity accumulated mean dose remained lower than the worst-case scenario for all patients. Parotid accumulated mean dose remained within the uncertainty bands for 18 of the 21 patients, and all were kept lower than RO-IMPT worst-case scenario for 88.7% and 84.5% for left and right parotids, respectively. Conclusion This study demonstrated that RO-IMPT plans account for most setup and anatomical uncertainties, except for large weight-loss changes that need to be tracked throughout the treatment course. We showed that sCTs could be a powerful decision tool for adaptation of these cases in order to reduce workload when using repeat CTs.

Daily patient geometry correction: application of NAL and eNAL protocols

Purpose: To test the NAL and eNAL correction protocols using daily patient setup displacements.Methods and material: In total, the analysis was performed for 749 and 797 kV CBCT images for gynecological and prostate patients, respectively, each of 30 patients. After the planning procedure, patients were set up on the treatment table in the treatment position every day. The on-line correction protocol was applied. KV CBCT images were acquired by means of x-ray lamp mounted orthogonally on Linac. Patient setup displacement was assigned. NAL and eNAL corrections protocols were simulated using daily data from online corrections for these two groups of patients. The overall systematic error and random error were calculated for each direction.Results: For the prostate group, the random errors for daily Raw data (no correction) in LAT, LONG, and VERT directions were 2.0 mm, 1.6 mm, and 3.2 mm, respectively. For NAL and eNAL protocols, they were in the range of 1.8 mm to 3.2 mm. For the gynecological group, the random errors were: for daily Raw data 2.2 mm, 1.7 mm, and 3.2 mm, respectively. For NAL and eNAL protocols, they were in the range of 2.0 to 3.4 mm.For the prostate group, values of systematic errors 1.8 mm, 1.8 mm, and 3.3 mm, respectively for Raw data. For NAL and eNAL protocols, these values were less than 1.8 mm. For the gynecological group, the systematic errors were 2.6 mm, 2.3 mm, and 2.8 mm, respectively, for Raw data. For NAL ana eNAL protocols less than 1.8 mm.For the gynecological group, for Raw data, 45% of the total displacement vectors exceeded 5 mm, whereas only 25% did after the NAL procedure and 29% after the eNAL procedure. For the prostate group, for Raw data, 34% of the total displacement vectors exceeded 5 mm, whereas only 22% did after NAL procedure and 28% after eNAL procedure Conclusions: For gynecological and prostate cancer patients, the NAL and eNAL correction protocols can be safely applied to substantially reduce setup errors.