C Buckey

Charged particle therapy versus photon therapy for paranasal sinus and nasal cavity malignant diseases: a systematic review and meta-analysis

BACKGROUND Malignant tumours arising within the nasal cavity and paranasal sinuses are rare and composed of several histological types, rendering controlled clinical trials to establish the best treatment impractical. We undertook a systematic review and meta-analysis to compare the clinical outcomes of patients treated with charged particle therapy with those of individuals receiving photon therapy. METHODS We identified studies of nasal cavity and paranasal sinus tumours through searches of databases including Embase, Medline, Scopus, and the Cochrane Collaboration. We included treatment-naive cohorts (both primary and adjuvant radiation therapy) and those with recurrent disease. Primary outcomes of interest were overall survival, disease-free survival, and locoregional control, at 5 years and at longest follow-up. We used random-effect models to pool outcomes across studies and compared event rates of combined outcomes for charged particle therapy and photon therapy using an interaction test. FINDINGS 43 cohorts from 41 non-comparative observational studies were included. Median follow-up for the charged particle therapy group was 38 months (range 5-73) and for the photon therapy group was 40 months (14-97). Pooled overall survival was significantly higher at 5 years for charged particle therapy than for photon therapy (relative risk 1·51, 95% CI 1·14-1·99; p=0·0038) and at longest follow-up (1·27, 1·01-1·59; p=0·037). At 5 years, disease-free survival was significantly higher for charged particle therapy than for photon therapy (1·93, 1·36-2·75, p=0·0003) but, at longest follow-up, this event rate did not differ between groups (1·51, 1·00-2·30; p=0·052). Locoregional control did not differ between treatment groups at 5 years (1·06, 0·68-1·67; p=0·79) but it was higher for charged particle therapy than for photon therapy at longest follow-up (1·18, 1·01-1·37; p=0·031). A subgroup analysis comparing proton beam therapy with intensity-modulated radiation therapy showed significantly higher disease-free survival at 5 years (relative risk 1·44, 95% CI 1·01-2·05; p=0·045) and locoregional control at longest follow-up (1·26, 1·05-1·51; p=0·011). INTERPRETATION Compared with photon therapy, charged particle therapy could be associated with better outcomes for patients with malignant diseases of the nasal cavity and paranasal sinuses. Prospective studies emphasising collection of patient-reported and functional outcomes are strongly encouraged. FUNDING Mayo Foundation for Medical Education and Research.

Treatment planning and delivery of IMRT using 6 and 18 MV photon beams without flattening filter

In light of the increasing use of intensity modulated radiation therapy (IMRT) in modern radiotherapy practice, the use of a flattening filter may no longer be necessary. Commissioning data have been measured for a Varian 23EX linear accelerator with 6 and 18 MV photon energies without a flattening filter. Measurements collected for the commissioning of the linac included percent depth dose curves and profiles for field sizes ranging from 2 x 2 to 40 x 40 cm(2) as defined by the jaws and multileaf collimator. Machine total scatter factors were measured and calculated. Measurements were used to model the unflattened beams with the Pinnacle(3) treatment planning system. IMRT plans for prostate, lung, brain and head and neck cancer cases were generated using the flattening filter and flattening filter-free beams. From our results, no difference in the quality of the treatment plans between the flat and unflattened photon beams was noted. There was however a significant decrease in the number of monitor units required for unflattened beam treatment plans due to the increase in linac output-approximately two times and four times higher for the 6 and 18 MV, respectively.

Evaluation of a commercially-available block for spatially fractionated radiation therapy

In this paper, we present the dosimetric characteristics of a commercially‐produced universal GRID block for spatially fractioned radiation therapy. The dosimetric properties of the GRID block were evaluated. Ionization chamber and film measurements using both Kodak EDR2 and Gafchromic EBT film were performed in a solid water phantom to determine the relative output of the GRID block as well as its spatial dosimetric characteristics. The surface dose under the block and at the openings was measured using ultra thin TLDs. After introducing the GRID block into the treatment planning system, a treatment plan was created using the GRID block and also by creating a GRID pattern using the multi‐leaf collimator. The percent depth doses measured with film showed that there is a shift of the dmax towards shallower depths for both energies (6 MV and 18 MV) under investigation. It was observed that the skin dose at the GRID openings was higher than the corresponding open field by a factor as high as 50% for both photon energies. The profiles showed the transmission under the block was in the order of 15–20% for 6 MV and 30% for 18 MV. The MUs calculated for a real patient using the block were about 80% less than the corresponding MUs for the same plan using the multileaf collimator to define the GRID. Based on this investigation, this brass GRID compensator is a viable alternative to other solid compensators or MLC‐based fields currently in use. Its ease of creation and use give it decided advantages. Its ability to be created once and used for multiple patients (by varying the collimation of the linear accelerator jaws) makes it attractive from a cost perspective. We believe this compensator can be put to clinical use, and will allow more centers to offer GRID therapy to their patients. PACS number: 87.53.Mr

The inter‐ and intrafraction reproducibilities of three common IMRT delivery techniques

PURPOSE Intensity modulated radiation therapy (IMRT) treatment delivery requires higher precision than conventional 3D treatment delivery because of the sensitivity of the resulting dose to small geometric misalignment of the modulated beamlets. The chosen treatment delivery technique will affect the treatment precision in different ways, based on the characteristics of the delivery method. Delivery using a multileaf collimator (MLC) can reduce treatment time and therapist workload, but typically requires a greater number of monitor units and the fields are prone to both systematic and random leaf positioning errors. An alternative to MLC-based fields, patient specific brass compensators, do not suffer from these leaf positioning errors. In our study, we set out to investigate which delivery method will provide the highest levels of dosimetric reproducibility and the minimum amount of interfraction variability. METHODS In our study, a seven field IMRT plan for a head and neck treatment was created using the Pinnacle3 treatment planning system and the intensity maps for each field were obtained. The intensity maps of the fields were delivered with a Varian 2100C/D linear accelerator, using solid compensators and sliding window (SW) and step-and-shoot (SS) MLC segments. Three fields were selected from the seven-beam IMRT plan for comparison. Analysis was carried out using the MatriXX ion chamber array, radiochromic film, and Varian dynalog files. RESULTS Our results show that the error in MLC leaf positioning has no gantry angle dependence. The compensator and SW deliveries showed excellent agreement, even when stricter than usual gamma criteria were applied. However, we noted that under these strict conditions, the SS field had at least ten times more pixels out of range than did the compensators. When using step-and-shoot MLC fields, it was observed that the increase in dose rate or the increase of MU/segment degrades the quality of the plan. Analysis of the dynalog files showed that while each individual field had its own propensity for error, all fields showed the same trend: a greater percentage of time the leaves are out of position as dose rate increases, MUs decrease, or both. CONCLUSIONS The compensator-based field and both types of MLC-based fields have MatriXX results that are within the clinically acceptable tolerance of 3% dose difference and 2 mm DTA. However, when the criteria are tightened, it becomes evident that the compensators have a definite advantage over their comparable MLC-based competitors in terms of interfraction reproducibility. Fewer monitor units are required to deliver each portal, potentially improving patient outcomes and reducing unwanted side effects to both patients and therapists. In centers without MLC, compensators represent a simple and cost effective way to offer patients state of the art treatment. Based on the results of this study, compensator-based IMRT is a reliable, viable option for use in clinics both with and without MLC-equipped linacs.

Dosimetric comparison between 3D conformal and intensity-modulated radiation therapy for prostate cancer

Background and Purpose: Intensity-modulated radiation therapy (IMRT) is considered by many to be the standard of care in the delivery of external-beam radiotherapy treatments to the prostate. The purpose of this study is to assess the validity of the purported benefits of IMRT. Materials and Methods: Treatment plans were produced for 10 patients using both 3D conformal radiation therapy (3D-CRT) and IMRT, utilising the dose constraints recommended by the Radiation Therapy Oncology Group (RTOG) 0415 protocol. Three IMRT modalities used in this study were linear accelerator based IMRT, helical tomotherapy, and serial tomotherapy. The prescription to the target, 76 Gy, was the same for all plans. Results: In general the 3D-CRT plans satisfied the RTOG criteria for planning target volume (PTV) coverage, and met or bettered the dose criteria for the organs at risk. PTV coverage was more homogeneous for the IMRT plans than the 3D-CRT plans but not significantly improved. Conclusions: Technically, because the IMRT plans required greater effort for the optimisation, longer treatment times and higher monitor units, the use of IMRT for the fulfilment of the protocol’s dosimetric goals was not justified using these constraints.

Radiobiological evaluation of prostate cancer IMRT and conformal-RT plans using different treatment protocols

The purpose of this study is to evaluate the clinical efficacy of both step-and-shoot IMRT and 3D-Conformal Radiation Therapy modalities (CRT) in treating prostate cancer using radiobiological measures. Another aim was to estimate the risks for developing secondary malignancies in bladder and rectum due to radiotherapy from the corresponding modalities. The treatment plans of ten prostate cancer patients were developed using IMRT and CRT. For the IMRT plans, two beam energies and two treatment protocols were used (the RTOG 0415 and a most restrictive one proposed by Fox Chase Cancer Center (FCCC)). For the evaluation of these plans, the complication-free tumor control probability, the total probability of injury, the total probability of control/benefit, and the biologically effective uniform dose were employed. Furthermore, based on the dosimetric data of IMRT and CRT, the risk for secondary malignancies was calculated for bladder and rectum. The average risk for secondary malignancy was lower for the bladder (0.37%) compared to the rectum (0.81%) based on all the treatment plans of the ten prostate cancer patients. The highest average risk for secondary malignancy for bladder and rectum was for the CRT-6X modality (0.46% and 1.12%, respectively) and the lowest was for the IMRT RTOG-18X modality (0.33% and 0.56%, respectively). The ≥ Grade 2 LENT/SOMA response probability was lower for the bladder than for the rectum in all the plans. For the bladder the highest average value was for the IMRT RTOG-18X (0.9%) and the lowest was for the CRT-18X modality (0.1%). For the rectum, the highest average value was for the IMRT RTOG-6X (11.9%) and the lowest was for the IMRT FCCC-18X modality (2.2%). By using radiobiological measures it is shown that the IMRT FCCC plans had the lowest risks for normal tissue complications, whereas the IMRT RTOG had the highest. Regarding the risk for secondary malignancies, the CRT plans showed the highest values for both bladder and rectum.

SU‐E‐T‐742: The Risk of Secondary Malignancies as An Evaluation Factor in the Comparison of Prostate Cancer Intensity Modulated Radiotherapy (IMRT) and Conformal Radiotherapy (CRT) Treatment Plans

Purpose: To examine the clinical efficacy of both MLC-based IMRT, and 3D-Conformal Radiation Therapy modalities (CRT) to treat prostate cancer using radiobiological measures. Furthermore, to investigate the risk for developing secondary malignancies in bladder and rectum due to radiotherapy from the corresponding modalities. Methods: Treatment plans for prostate cancer were developed using IMRT and CRT for ten patients. For the IMRT plans, two different treatment protocols were used (RTOG and FCCC). For the evaluation of these plans, the complication-free tumor control probability, the total probability of injury, the total probability of control/benefit, and the biologically effective uniform dose were employed. Furthermore, based on the dosimetric data of IMRT and CRT, the risk for secondary malignancies was calculated for bladder and rectum. Results: The average risk for secondary malignancy was lower for the bladder (0.37%) compared to the rectum (0.81%) based on all the treatment plans of the ten prostate cancer patients. The highest average risk for secondary malignancy for bladder and rectum was for the 6X 3D modality (0.46% and 1.12%, respectively) and the lowest was for the 18X IMRT RTOG modality (0.33% and 0.56%, respectively). The response probability was lower for the bladder than for the rectum in all the plans. For the bladder the highest value was for the 18X IMRT FCCC (0.03%) and the lowest was for the 18X 3D modality (0.0%). For the rectum, the highest value was for the 6X IMRT RTOG (3.52%) and the lowest was for the 18X IMRT FCCC modality (0.41%). Conclusion: By using radiobiological measures it is shown that the IMRT FCCC plans had the lowest risks for normal tissue complications, whereas the IMRT RTOG had the highest. Regarding the risk for secondary malignancies, the CRT plans showed the highest values both in bladder and rectum.

SU‐E‐T‐151: Application of a 2D Ionization Chamber Array for Monthly and Annual Linear Accelerator QA

Purpose: An evaluation of a commercially available 2D array for monthly and annual linear accelerator QA. Methods: The 2D‐ARRAY seven29 (PTW, Freiburg, Germany) is a two‐dimensional ion chamber array, consisting of 729 (27 × 27) vented ion chambers, with separately housed evaluation electronics. The parallel‐plate chambers are 5 × 5 × 5 mm in size, and have a center to center spacing of 10 mm. To increase resolution, the array can be shifted three times in increments of 5 mm, and the resulting 2916 measurement points can be summed into one image. The array was placed under 10 cm of water‐equivalent material, and irradiated to evaluate: flatness and symmetry, static MLC positioning, dynamic MLC positioning, and output. It was also irradiated without any buildup for the light field and radiation coincidence test. All deliveries were completed using a Varian 2100 C/D linear accelerator with a Millennium‐80 MLC. For improved accuracy, the static and dynamic MLC fields were delivered 4 times each, and were then summed using the “merge” function in the PTW VeriSoft software. Results: Over one month of data acquisition, output fluctuated less than 2%. For light field and radiation coincidence, reproducibility is excellent, with a maximum of 1% variation in asymmetric jaw settings. When using the “merge” function on dynamic MLCmeasurements, results were less than 4% for transmission and 0.5 mm for positioning errors. Measurements for flatness and symmetry and static MLC positioning also had good reproducibility. Conclusions: The PTW 2D‐Array seven29 can be used to evaluate many areas of monthly linear accelerator QA. Particularly in light of the trend for departments to go filmless, it is a viable alternative for obtaining flatness and symmetry, static and dynamic MLC positioning, light field and radiation coincidence, and for measuring output. This work partially supported by PTW (Freiburg, Germany).

SU‐GG‐T‐503: Do Stricter IMRT Planning Constraints Produce Better Radiobiological Results?

Purpose: Widely used for prostate cancer treatment, IMRT provides more conformal dose to target and better sparing of the critical normal structures than 3DCRT. It has been shown that the stricter constraints in IMRT planning provide better dosimetric results. The purpose of this study is to assess if the stricter constraints also produce better biological consequence by using the biological effective uniform dose (BEUD) and complication‐free tumor control probability (P +). Method and Materials: The IMRT plans were created for 9 and 7 prostate cancer patients respectively with 6 MV and 18 MV photon beams, using two IMRT planning dose/volume constrains of OARs: from RTOG 0415 (RTOG) and from published data with stricter constrains (FCCC), separately. For each patient, the contours of prostate (GTV=PTV), bladder, rectum, left and right femoral heads, and penile bulb were delineated on planning CT by the same physician. The biological difference of corresponding plans was measured and compared by the BEUD (D) and P+. Results: At the optimum dose levels of the RTOG dose constraint using 6 and 18 MV photons, the P + is 61.1% for a DPTV of 90.4 Gy and 62.6% for a DPTV of 90.3 Gy, respectively, and the corresponding total tumor control probabilities PB are 89.2% and 88.9%, whereas the total complication probabilities PI are 28.1% and 26.3%, respectively.. At the optimum dose levels of the stricter FCCC dose constraint using 6 and 18 MV photons, the P + is 84.6% for a DPTV of 95.4 Gy and 77% for a DPTV of 92.8 Gy. The corresponding total tumor cation probabilities PB are 95.1% and 92.8%, whereas the total complication probabilities PI are 10.5% and 15.8%, respectively. Conclusion: The more stringent IMRT planning constraints leads to better radiobiological outcome for prostate cancer treatment at the same beam energy.

SU‐GG‐T‐561: The Effect of MLC Leaf Width in RapidArc Plan Optimization

Purpose: To evaluate the effect of the leaf width during RapidArc optimization Materials and Methods: Twenty patients were randomly selected from out departments database that were previously planned using the Eclipse treatment planning system with the RapidArc optimization capabilities. Prostate, brain,lung,liver and head and neck were the sites that were evaluated in this study. For each patient three plans were generated using linear accelerators with 120 Millennium, 120 High definition and 80 Millennium multileaf collimators. Each plan consisted of 2 arcs of the same span. The collimators of each arc were rotated by 90 degrees with respect to each other. The isocenter location and optimization parameters were kept the same for each plan within each patient. The DVH and isodose distributions were chosen for the evaluation and comparison of the plans. Results: The comparison of the DVHs showed that the high definition MLC produced superior plans with respect to PTV coverage. Also, lower critical organ doses were calculated for the high definition MLC optimized. The millennium 80 MLC produced the most inferior plans for all cases. The plan quality was similar between the 120 and 80 millennium MLC for targets that were lateral with the respect to the central axis of the beam where the MLC leaf width was the same. Conclusions: The MLC leaf width plays an important role during the plan optimization for centrally located targets. A superior plan is achieved with smaller MLC leaf width.