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DOE OSTI2014

Sci—Thur AM: YIS - 05: 10X-FFF VMAT for Lung SABR: an Investigation of Peripheral Dose

Flattening Filter Free (FFF) beams exhibit high dose rates, reduced head scatter, leaf transmission and leakage radiation. For VMAT lung SABR, treatment time can be significantly reduced using high dose rate FFF beams while maintaining plan quality and accuracy. Another possible advantage offered by FFF beams for VMAT lung SABR is the reduction in peripheral dose. The focus of this study was to investigate and quantify the reduction of peripheral dose offered by FFF beams for VMAT lung SABR. The peripheral doses delivered by VMAT Lung SABR treatments using FFF and flattened beams were investigated for the Varian Truebeam linac. This study was conducted in three stages, (1): ion chamber measurement of peripheral dose for various plans, (2): validation of AAA, Acuros XB and Monte Carlo for peripheral dose using measured data, and (3): using the validated Monte Carlo model to evaluate peripheral doses for 6 VMAT lung SABR treatments. Three energies, 6X, 10X, and 10X-FFF were used for all stages. Measured data indicates that 10X-FFF delivers the lowest peripheral dose of the three energies studied. AAA and Acuros XB dose calculation algorithms were identified as inadequate, and Monte Carlo was validated for accurate peripheral dose prediction. The Monte Carlo-calculated VMAT lung SABR plans show a significant reduction in peripheral dose for 10X-FFF plans compared to the standard 6X plans, while no significant reduction was showed when compared to 10X. This reduction combined with shorter treatment time makes 10X-FFF beams the optimal choice for superior VMAT lung SABR treatments.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2014

Radiation dose calculations for CT scans with tube current modulation using the approach to equilibrium function

Purpose: The approach to equilibrium function has been used previously to calculate the radiation dose to a shift-invariant medium undergoing CT scans with constant tube current [Li, Zhang, and Liu, Med. Phys. 39, 5347–5352 (2012)]. The authors have adapted this method to CT scans with tube current modulation (TCM). Methods: For a scan with variable tube current, the scan range was divided into multiple subscan ranges, each with a nearly constant tube current. Then the dose calculation algorithm presented previously was applied. For a clinical CT scan series that presented tube current per slice, the authors adopted an efficient approach that computed the longitudinal dose distribution for one scan length equal to the slice thickness, which center was at z = 0. The cumulative dose at a specific point was a summation of the contributions from all slices and the overscan. Results: The dose calculations performed for a total of four constant and variable tube current distributions agreed with the published results of Dixon and Boone [Med. Phys. 40, 111920 (14pp.) (2013)]. For an abdomen/pelvis scan of an anthropomorphic phantom (model ATOM 701-B, CIRS, Inc., VA) on a GE Lightspeed Pro 16 scanner with 120 kV, N × T = 20 mm, pitch = 1.375, z axis current modulation (auto mA), and angular current modulation (smart mA), dose measurements were performed using two lines of optically stimulated luminescence dosimeters, one of which was placed near the phantom center and the other on the surface. Dose calculations were performed on the central and peripheral axes of a cylinder containing water, whose cross-sectional mass was about equal to that of the ATOM phantom in its abdominal region, and the results agreed with the measurements within 28.4%. Conclusions: The described method provides an effective approach that takes into account subject size, scan length, and constant or variable tube current to evaluate CT dose to a shift-invariant medium. For a clinical CT scan, dose calculations may be performed with a water-containing cylinder whose cross-sectional mass is equal to that of the subject. This method has the potential to substantially improve evaluations of patient dose from clinical CT scans, compared to CTDI{sub vol}, size-specific dose estimate (SSDE), or the dose evaluated for a TCM scan with a constant tube current equal to the average tube current of the TCM scan.

62 RADIOLOGY AND NUCLEAR MEDICINE↗
DOE OSTI2015

SU-E-I-06: A Dose Calculation Algorithm for KV Diagnostic Imaging Beams by Empirical Modeling

Purpose: To develop accurate three-dimensional (3D) empirical dose calculation model for kV diagnostic beams for different radiographic and CT imaging techniques. Methods: Dose was modeled using photon attenuation measured using depth dose (DD), scatter radiation of the source and medium, and off-axis ratio (OAR) profiles. Measurements were performed using single-diode in water and a diode-array detector (MapCHECK2) with kV on-board imagers (OBI) integrated with Varian TrueBeam and Trilogy linacs. The dose parameters were measured for three energies: 80, 100, and 125 kVp with and without bowtie filters using field sizes 1×1–40×40 cm2 and depths 0–20 cm in water tank. Results: The measured DD decreased with depth in water because of photon attenuation, while it increased with field size due to increased scatter radiation from medium. DD curves varied with energy and filters where they increased with higher energies and beam hardening from half-fan and full-fan bowtie filters. Scatter radiation factors increased with field sizes and higher energies. The OAR was with 3% for beam profiles within the flat dose regions. The heal effect of this kV OBI system was within 6% from the central axis value at different depths. The presence of bowtie filters attenuated measured dose off-axis by as much as 80% at the edges of large beams. The model dose predictions were verified with measured doses using single point diode and ionization chamber or two-dimensional diode-array detectors inserted in solid water phantoms. Conclusion: This empirical model enables fast and accurate 3D dose calculation in water within 5% in regions with near charge-particle equilibrium conditions outside buildup region and penumbra. It considers accurately scatter radiation contribution in water which is superior to air-kerma or CTDI dose measurements used usually in dose calculation for diagnostic imaging beams. Considering heterogeneity corrections in this model will enable patient specific dose calculation.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2015

SU-E-T-92: Achieving Desirable Lung Doses in Total Body Irradiation Based On in Vivo Dosimetry and Custom Tissue Compensation

Purpose: To achieve desirable lung doses in total body irradiation (TBI) based on in vivo dosimetry and custom tissue compensation. Methods: The 15 MV photon beam of a Varian TrueBeam STx linac was used for TBI. Patients were positioned in the lateral decubitus position for AP/PA treatment delivery. Dose was calculated using the midpoint of the separation distance across the patient’s umbilicus. Patients received 200 cGy twice daily for 3 days. The dose rate at the patient’s midplane was approximately 10 cGy/min. Cerrobend blocks with a 5-HVL thickness were used for the primary lung shielding. A custom styrofoam holder for rice-flour filled bags was created based on the lung block cutouts. This was used to provide further lung shielding based on in vivo dose measurements. Lucite plates and rice-flour bags were placed in the head, neck, chest, and lower extremity regions during the treatment to compensate for the beam off-axis output variations. Two patients were included in the study. Patients 1 and 2 received a craniospinal treatment (1080 cGy) and a mediastinum treatment (2520 cGy), respectively, before the TBI. During the TBI nanoDot dosimeters were placed on the patient skin in the forehead, neck, umbilicus, and lung regions for dose monitoring. The doses were readout immediately after the treatment. Based on the readings, fine tuning of the thickness of the rice-flour filled bags was exploited to achieve the desirable lung doses. Results: For both patients the mean lung doses, which took into consideration all treatments, were controlled within 900 +/−10% cGy, as desired. Doses to the forehead, neck, and umbilicus were achieved within +/−10% of the prescribed dose (1200 cGy). Conclusion: A reliable and robust method was developed to achieve desirable lung doses and uniform body dose in TBI based on in vivo dosimetry and custom tissue compensator.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2015

SU-E-T-135: Assessing the Clinical Impact of Approximations in Analytical Dose Calculations for Proton Therapy

Purpose: To estimate the clinical relevance of approximations made in analytical dose calculation methods (ADCs) used for treatment planning on tumor coverage and tumor control probability (TCP) in proton therapy. Methods: We compared dose distributions planned with ADC to delivered dose distributions (as determined by TOPAS Monte Carlo (MC) simulations). We investigated 10 patients per site for 5 treatment sites (head-and-neck, lung, breast, prostate, liver). We evaluated differences between the two dose distributions analyzing dosimetric indices based on the dose-volume-histograms, the γ-index and the TCP. The normal tissue complication probability (NTCP) was estimated for the bladder and anterior rectum for the prostate patients. Results: We find that the target doses are overestimated by the ADC by 1–2% on average for all patients considered. All dosimetric indices (the mean dose, D95, D50 and D02, the dose values covering 95%, 50% and 2% of the target volume, respectively) are predicted within 5% of the delivered dose. A γ-index with a 3%/3mm criteria had a passing rate for target volumes above 96% for all patients. The TCP predicted by the two algorithms was up to 2%, 2.5%, 6%, 6.5%, and 11% for liver and breast, prostate, head-and-neck and lung patients, respectively. Differences in NTCP for anterior-rectum and bladder for prostate patients were less than 3%. Conclusion: We show that ADC provide adequate dose distributions for most patients, however, they can Result in underdosage of the target by as much as 5%. The TCP was found to be up to 11% lower than predicted. Advanced dose-calculation methods like MC simulations may be necessary in proton therapy to ensure target coverage for heterogeneous patient geometries, in clinical trials comparing proton therapy to conventional radiotherapy to avoid biases due to systematic discrepancies in calculated dose distributions, and, if tighter range margins are considered. Fully funded by NIH grants.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2015

SU-E-T-256: Development of a Monte Carlo-Based Dose-Calculation System in a Cloud Environment for IMRT and VMAT Dosimetric Verification

Purpose: Intensity-modulated radiation therapy (IMRT) and volumetric-modulated arc therapy (VMAT) are techniques that are widely used for treating cancer due to better target coverage and critical structure sparing. The increasing complexity of IMRT and VMAT plans leads to decreases in dose calculation accuracy. Monte Carlo simulations are the most accurate method for the determination of dose distributions in patients. However, the simulation settings for modeling an accurate treatment head are very complex and time consuming. The purpose of this work is to report our implementation of a simple Monte Carlo simulation system in a cloud-computing environment for dosimetric verification of IMRT and VMAT plans. Methods: Monte Carlo simulations of a Varian Clinac linear accelerator were performed using the BEAMnrc code, and dose distributions were calculated using the DOSXYZnrc code. Input files for the simulations were automatically generated from DICOM RT files by the developed web application. We therefore must only upload the DICOM RT files through the web interface, and the simulations are run in the cloud. The calculated dose distributions were exported to RT Dose files that can be downloaded through the web interface. The accuracy of the calculated dose distribution was verified by dose measurements. Results: IMRT and VMAT simulations were performed and good agreement results were observed for measured and MC dose comparison. Gamma analysis with a 3% dose and 3 mm DTA criteria shows a mean gamma index value of 95% for the studied cases. Conclusion: A Monte Carlo-based dose calculation system has been successfully implemented in a cloud environment. The developed system can be used for independent dose verification of IMRT and VMAT plans in routine clinical practice. The system will also be helpful for improving accuracy in beam modeling and dose calculation in treatment planning systems. This work was supported by JSPS KAKENHI Grant Number 25861057.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2015

SU-E-T-288: Dose Volume Population Histogram (DVPH): A New Method to Evaluate Intensity Modulated Proton Therapy Plans With Geometrical Uncertainties

Purpose: In Proton therapy, especially intensity modulated proton therapy(IMPT), the dose distribution shape is very sensitive to errors due to sharp dose gradients at the Bragg peaks. The concept of the conventional margin is based on the assumption that dose distribution is shifted rather than deformed due to geometrical uncertainties. The goal of this study is to access the validity of the margin concept as well as propose a new approach using Dose Volume Population Histogram (DVPH) in evaluating IMPT plans. Methods: For a prostate case, an intensity modulated proton therapy is optimized based on the conventional PTV based objective function. The plan is evaluated based on the PTV DVH and CTV DVPH (dose volume population histogram) which explicitly taking into account geometric uncertainties. The DVPH is calculated based on 2197 dose distributions at different CTV possible positions for both random and systematic errors. The DVPH with a 90% confidence level is used for the comparison. Results: The minimum dose of the CTV DVPH with a 90% confidence level is only about 18% of the prescribed dose, while the minimum dose of the PTV is 95%. For bladder DVHs, the D50 and D35 is 26% and 30%, compared to 65% and 70% of the prescribed dose from the bladder DVPH with 90% confidence level. Conclusion: The results showed that the PTV concept for ensuring the prescribed dose actually delivered to the CTV is invalid in proton therapy. The good PTV DVH might Result in an underdose to the target and should not be used for IMPT optimization. For OARs, the conventional evaluation approach underestimates dose volume end points. The new concept DVPH has been proved to provide a more accurate DVH evaluation in proton therapy.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2015

SU-E-T-762: Toward Volume-Based Independent Dose Verification as Secondary Check

Purpose: Lung SBRT plan has been shifted to volume prescription technique. However, point dose agreement is still verified using independent dose verification at the secondary check. The volume dose verification is more affected by inhomogeneous correction rather than point dose verification currently used as the check. A feasibility study for volume dose verification was conducted in lung SBRT plan. Methods: Six SBRT plans were collected in our institute. Two dose distributions with / without inhomogeneous correction were generated using Adaptive Convolve (AC) in Pinnacle3. Simple MU Analysis (SMU, Triangle Product, Ishikawa, JP) was used as the independent dose verification software program, in which a modified Clarkson-based algorithm was implemented and radiological path length was computed using CT images independently to the treatment planning system. The agreement in point dose and mean dose between the AC with / without the correction and the SMU were assessed. Results: In the point dose evaluation for the center of the GTV, the difference shows the systematic shift (4.5% ± 1.9 %) in comparison of the AC with the inhomogeneous correction, on the other hands, there was good agreement of 0.2 ± 0.9% between the SMU and the AC without the correction. In the volume evaluation, there were significant differences in mean dose for not only PTV (14.2 ± 5.1 %) but also GTV (8.0 ± 5.1 %) compared to the AC with the correction. Without the correction, the SMU showed good agreement for GTV (1.5 ± 0.9%) as well as PTV (0.9% ± 1.0%). Conclusion: The volume evaluation for secondary check may be possible in homogenous region. However, the volume including the inhomogeneous media would make larger discrepancy. Dose calculation algorithm for independent verification needs to be modified to take into account the inhomogeneous correction.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2015

SU-E-T-806: Very Fast GPU-Based IMPT Dose Computation

Purpose: Designing particle therapy treatment plans is a dosimetrist-in-the-loop optimization wherein the conflicting constraints of achieving a desired tumor dose distribution must be balanced against the need to minimize the dose to nearby OARs. IMPT introduces an additional, inner, numerical optimization step in which the dosimetrist’s current set of constraints are used to determine the weighting of beam spots. Very fast dose calculations are needed to enable the dosimetrist to perform many iterations of the outer optimization in a commercially reasonable time. Methods: We have developed a GPU-based convolution-type dose computation algorithm that more accurately handles heterogeneities than earlier algorithms by redistributing energy from dose computed in a water volume. The depth dependence of the beam size is handled by pre-processing Bragg curves using a weighted superposition of Gaussian bases. Additionally, scattering, the orientation of treatment ports, and the non-parallel propagation of beams are handled by large, but sparse, energy-redistribution matrices that implement affine transforms. Results: We tested our algorithm using a brain tumor dataset with 1 mm voxels and a single treatment port from the patient’s anterior through the sinuses. The resulting dose volume is 100 × 100 × 230 mm with 66,200 beam spots on a 3 × 3 × 2 mm grid. The dose computation takes <1 msec on a GeForce GTX Titan GPU with the Gamma passing rate for 2mm/2% criterion of 99.1% compared to dose calculated by an alternative dose algorithm based on pencil beams. We will present comparisons to Monte Carlo dose calculations. Conclusion: Our high-speed dose computation method enables the IMPT spot weights to be optimized in <1 second, resulting in a nearly instantaneous response to user changes to dose constraints. This permits the creation of higher quality plans by allowing the dosimetrist to evaluate more alternatives in a short period of time.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2016

A Parametric Analysis of Factors Affecting Calculations of Estimated Dose Rates from Spent Nuclear Fuel Shipments - 16458

Planning for transportation of SNF requires estimation of the radiation dose to the members of the public associated with the transportation. This dose is expected to be very low compared to natural background radiation because dose rates and exposure durations are minimal. A preliminary investigation was performed to estimate the dose rate from a SNF transportation package as a function of distance and evaluate factors affecting the estimated dose rate, such as local environment modeling. Effects on the dose rate are determined for changes in temperature and relative humidity of the air surrounding a transportation package and for different compositions of the ground underneath it. The impact of different vapor content in air was evaluated to be small, within the statistical uncertainty of the dose rate estimates. The neutron dose rate contributions from scattering interactions within different soil/pavement materials were from approximately 20% to 70% at 25 cm from the ground and from approximately 10% to 40% at 175 cm from the ground. The effect of photon scattering interactions within different soil/pavement materials was an increase in photon dose rate of less than 20% at 25 cm from the ground and less than 10% at 175 cm from the ground. The impact of different ground materials on the total dose rate would depend on the relative contributions of photon and neutron dose rates to the total dose rate. (authors)

12 MANAGEMENT OF RADIOACTIVE AND NON-RADIOACTIVE W↗
DOE OSTI2014

Estimated External Doses to Members of the Public from Patients with {sup 131}I Treatment - Paper 143

To protect individuals from the radiation emitted by a patient receiving {sup 131}I treatment a licensee must estimate the maximum likely effective dose to members of the public. Under current guidance by the United States Nuclear Regulatory Commission (NRC), a licensee may authorize the release of the patient if the effective dose is unlikely to exceed 5 mSv. NRC provides guidance to its licensees, in NRC Regulatory Guide 8.39, on acceptable methods that may be used to calculate the dose to a member of the public that may result from releasing the patient. To further assist licensees in implementing the regulation, NRC used conservative assumptions to estimate the activity of radionuclide in a patient, and the dose rate at 1 meter from the patient, that would be indicators of a potential dose to a member of the public of 5 mSv. Licensees may use these tables as operational criteria for releasing a patient if the conservative assumptions are considered acceptable. Licensees may also perform their own calculations, using case-specific assumptions, to show compliance with 5 mSv release criterion. The scope of this work is to provide dose coefficients for a variety of plausible public exposure scenarios that could be used by licensees to to show compliance. In the patient-specific calculations, the licensee is free to consider factors such as occupancy factor, effective half-life of the radionuclide in the patient's body, and tissue shielding. A conservative method of calculating the maximum likely dose to members of the public is provided in NRC Reg. Guide 8.39, which assumes no tissue attenuation of by the patient's body, no biological component that reduces the effective half-life of the radionuclide, and the patient's body burden is a point source. The assumption of no biological removal from the body introduces some conservatism into dose estimates for {sup 131}I. Also, it has been shown that the assumption of a point source with no tissue attenuation substantially overestimates the dose rate to nearby persons. The current method for calculating the maximum dose rate to members of the public from a nuclear medicine patient provided in US-NRC Regulatory Guide 8.39 assumes the patient's body burden is a point-source. Lack of consideration of tissue attenuation by the patient's body and biological removal of the radionuclide leads to a substantial overestimate of the actual external dose rate to a nearby member of the public. However, use of these assumptions in estimating potential dose to a member of the public simplifies the calculations considerably and, although generally conservative, the calculations serve as a useful screening tool. Many, if not most patients, could be released on that basis. If not, then refined calculations may be used, and the coefficients described in this paper provide one of the means for refining the calculations in cases where the screening calculations were not adequate. (authors)

61 RADIATION PROTECTION AND DOSIMETRY↗
DOE OSTI2017

Real-Time Patient and Staff Radiation Dose Monitoring in IR Practice

PurposeKnowledge of medical radiation exposure permits application of radiation protection principles. In our center, the first dedicated real-time, automated patient and staff dose monitoring system (DoseWise Portal, Philips Healthcare) was installed. Aim of this study was to obtain insight in the procedural and occupational doses.Materials and MethodsAll interventional radiologists, vascular surgeons, and technicians wore personal dose meters (PDMs, DoseAware, Philips Healthcare). The dose monitoring system simultaneously registered for each procedure dose-related data as the dose area product (DAP) and effective staff dose (E) from PDMs. Use and type of shielding were recorded separately. All procedures were analyzed according to procedure type; these included among others cerebral interventions (n = 112), iliac and/or caval venous recanalization procedures (n = 68), endovascular aortic repair procedures (n = 63), biliary duct interventions (n = 58), and percutaneous gastrostomy procedure (n = 28).ResultsMedian (±IQR) DAP doses ranged from 2.0 (0.8–3.1) (percutaneous gastrostomy) to 84 (53–147) Gy cm{sup 2} (aortic repair procedures). Median (±IQR) first operator doses ranged from 1.6 (1.1–5.0) μSv to 33.4 (12.1–125.0) for these procedures, respectively. The relative exposure, determined as first operator dose normalized to procedural DAP, ranged from 1.9 in biliary interventions to 0.1 μSv/Gy cm{sup 2} in cerebral interventions, indicating large variation in staff dose per unit DAP among the procedure types.ConclusionReal-time dose monitoring was able to identify the types of interventions with either an absolute or relatively high staff dose, and may allow for specific optimization of radiation protection.

62 RADIOLOGY AND NUCLEAR MEDICINE↗
DOE OSTI2017

Low doses and non-targeted effects in environmental radiation protection; where are we now and where should we go?

The field of low dose radiobiology has advanced considerably in the last 30 years from small indications in the 1980's that all was not simple, to a paradigm shift which occurred during the 1990's, which severely dented the dose-driven models and DNA centric theories which had dominated until then. However while the science has evolved, the application of that science in environmental health protection has not. A reason for this appears to be the uncertainties regarding the shape of the low dose response curve, which lead regulators to adopt a precautionary approach to radiation protection. Radiation protection models assume a linear relationship between dose (i.e. energy deposition) and effect (in this case probability of an adverse DNA interaction leading to a mutation). This model does not consider non-targeted effects (NTE) such as bystander effects or delayed effects, which occur in progeny cells or offspring not directly receiving energy deposition from the dose. There is huge controversy concerning the role of NTE with some saying they reflect “biology” and that repair and homeostatic mechanisms sort out the apparent damage while others consider them to be a class of damage which increases the size of the target. One thing which has recently become apparent is that NTE may be very critical for modelling long-term effects at the level of the population rather than the individual. The issue is that NTE resulting from an acute high dose such as occurred after the A-bomb or Chernobyl occur in parallel with chronic effects induced by the continuing residual effects due to radiation dose decay. This means that if ambient radiation doses are measured for example 25 years after the Chernobyl accident, they only represent a portion of the dose effect because the contribution of NTE is not included. - Highlights: • This paper presents a new concept in Environmental Radiobiology, which could explain why effects are detected in Chernobyl and Fukushima wildlife at ambient doses which are very low. • We suggest that non-targeted effects such as genomic instability, lethal mutations and bystander signalling, contribute a persistent legacy dimension to the total measured effect. • This “historic dose” component needs to be incorporated into dose effect models in order to predict true levels of risk.

54 ENVIRONMENTAL SCIENCES↗
DOE OSTI2013

Second Solid Cancers After Radiation Therapy: A Systematic Review of the Epidemiologic Studies of the Radiation Dose-Response Relationship

Rapid innovations in radiation therapy techniques have resulted in an urgent need for risk projection models for second cancer risks from high-dose radiation exposure, because direct observation of the late effects of newer treatments will require patient follow-up for a decade or more. However, the patterns of cancer risk after fractionated high-dose radiation are much less well understood than those after lower-dose exposures (0.1-5 Gy). In particular, there is uncertainty about the shape of the dose-response curve at high doses and about the magnitude of the second cancer risk per unit dose. We reviewed the available evidence from epidemiologic studies of second solid cancers in organs that received high-dose exposure (>5 Gy) from radiation therapy where dose-response curves were estimated from individual organ-specific doses. We included 28 eligible studies with 3434 second cancer patients across 11 second solid cancers. Overall, there was little evidence that the dose-response curve was nonlinear in the direction of a downturn in risk, even at organ doses of ≥60 Gy. Thyroid cancer was the only exception, with evidence of a downturn after 20 Gy. Generally the excess relative risk per Gray, taking account of age and sex, was 5 to 10 times lower than the risk from acute exposures of <2 Gy among the Japanese atomic bomb survivors. However, the magnitude of the reduction in risk varied according to the second cancer. The results of our review provide insights into radiation carcinogenesis from fractionated high-dose exposures and are generally consistent with current theoretical models. The results can be used to refine the development of second solid cancer risk projection models for novel radiation therapy techniques.

62 RADIOLOGY AND NUCLEAR MEDICINE↗
DOE OSTI2013

Use of 4-Dimensional Computed Tomography-Based Ventilation Imaging to Correlate Lung Dose and Function With Clinical Outcomes

Purpose: Four-dimensional computed tomography (4DCT)-based ventilation is an emerging imaging modality that can be used in the thoracic treatment planning process. The clinical benefit of using ventilation images in radiation treatment plans remains to be tested. The purpose of the current work was to test the potential benefit of using ventilation in treatment planning by evaluating whether dose to highly ventilated regions of the lung resulted in increased incidence of clinical toxicity. Methods and Materials: Pretreatment 4DCT data were used to compute pretreatment ventilation images for 96 lung cancer patients. Ventilation images were calculated using 4DCT data, deformable image registration, and a density-change based algorithm. Dose–volume and ventilation-based dose function metrics were computed for each patient. The ability of the dose–volume and ventilation-based dose–function metrics to predict for severe (grade 3+) radiation pneumonitis was assessed using logistic regression analysis, area under the curve (AUC) metrics, and bootstrap methods. Results: A specific patient example is presented that demonstrates how incorporating ventilation-based functional information can help separate patients with and without toxicity. The logistic regression significance values were all lower for the dose–function metrics (range P=.093-.250) than for their dose–volume equivalents (range, P=.331-.580). The AUC values were all greater for the dose–function metrics (range, 0.569-0.620) than for their dose–volume equivalents (range, 0.500-0.544). Bootstrap results revealed an improvement in model fit using dose–function metrics compared to dose–volume metrics that approached significance (range, P=.118-.155). Conclusions: To our knowledge, this is the first study that attempts to correlate lung dose and 4DCT ventilation-based function to thoracic toxicity after radiation therapy. Although the results were not significant at the .05 level, our data suggests that incorporating ventilation-based functional imaging can improve prediction for radiation pneumonitis. We present an important first step toward validating the use of 4DCT-based ventilation imaging in thoracic treatment planning.

62 RADIOLOGY AND NUCLEAR MEDICINE↗
DOE OSTI2013

Retrospective Cohort Study of Bronchial Doses and Radiation-Induced Atelectasis After Stereotactic Body Radiation Therapy of Lung Tumors Located Close to the Bronchial Tree

Purpose: To evaluate the dose–response relationship between radiation-induced atelectasis after stereotactic body radiation therapy (SBRT) and bronchial dose. Methods and Materials: Seventy-four patients treated with SBRT for tumors close to main, lobar, or segmental bronchi were selected. The association between incidence of atelectasis and bronchial dose parameters (maximum point-dose and minimum dose to the high-dose bronchial volume [ranging from 0.1 cm{sup 3} up to 2.0 cm{sup 3}]) was statistically evaluated with survival analysis models. Results: Prescribed doses varied between 4 and 20 Gy per fraction in 2-5 fractions. Eighteen patients (24.3%) developed atelectasis considered to be radiation-induced. Statistical analysis showed a significant correlation between the incidence of radiation-induced atelectasis and minimum dose to the high-dose bronchial volumes, of which 0.1 cm{sup 3} (D{sub 0.1cm3}) was used for further analysis. The median value of D{sub 0.1cm3} (α/β = 3 Gy) was EQD{sub 2,LQ} = 147 Gy{sub 3} (range, 20-293 Gy{sub 3}). For patients who developed atelectasis the median value was EQD{sub 2,LQ} = 210 Gy{sub 3}, and for patients who did not develop atelectasis, EQD{sub 2,LQ} = 105 Gy{sub 3}. Median time from treatment to development of atelectasis was 8.0 months (range, 1.1-30.1 months). Conclusion: In this retrospective study a significant dose–response relationship between the incidence of atelectasis and the dose to the high-dose volume of the bronchi is shown.

62 RADIOLOGY AND NUCLEAR MEDICINE↗
DOE OSTI2014

Uveal Melanoma Treated With Iodine-125 Episcleral Plaque: An Analysis of Dose on Disease Control and Visual Outcomes

Purpose: To investigate, in the treatment of uveal melanomas, how tumor control, radiation toxicity, and visual outcomes are affected by the radiation dose at the tumor apex. Methods and Materials: A retrospective review was performed to evaluate patients treated for uveal melanoma with {sup 125}I plaques between 1988 and 2010. Radiation dose is reported as dose to tumor apex and dose to 5 mm. Primary endpoints included time to local failure, distant failure, and death. Secondary endpoints included eye preservation, visual acuity, and radiation-related complications. Univariate and multivariate analyses were performed to determine associations between radiation dose and the endpoint variables. Results: One hundred ninety patients with sufficient data to evaluate the endpoints were included. The 5-year local control rate was 91%. The 5-year distant metastases rate was 10%. The 5-year overall survival rate was 84%. There were no differences in outcome (local control, distant metastases, overall survival) when dose was stratified by apex dose quartile (<69 Gy, 69-81 Gy, 81-89 Gy, >89 Gy). However, increasing apex dose and dose to 5-mm depth were correlated with greater visual acuity loss (P=.02, P=.0006), worse final visual acuity (P=.02, P<.0001), and radiation complications (P<.0001, P=.0009). In addition, enucleation rates were worse with increasing quartiles of dose to 5 mm (P=.0001). Conclusions: Doses at least as low as 69 Gy prescribed to the tumor apex achieve rates of local control, distant metastasis–free survival, and overall survival that are similar to radiation doses of 85 Gy to the tumor apex, but with improved visual outcomes.

62 RADIOLOGY AND NUCLEAR MEDICINE↗
DOE OSTI2014

Increasing Use of Dose-Escalated External Beam Radiation Therapy for Men With Nonmetastatic Prostate Cancer

Purpose: To examine recent practice patterns, using a large national cancer registry, to understand the extent to which dose-escalated external beam radiation therapy (EBRT) has been incorporated into routine clinical practice for men with prostate cancer. Methods and Materials: We conducted a retrospective observational cohort study using the National Cancer Data Base, a nationwide oncology outcomes database in the United States. We identified 98,755 men diagnosed with nonmetastatic prostate cancer between 2006 and 2011 who received definitive EBRT and classified patients into National Comprehensive Cancer Network (NCCN) risk groups. We defined dose-escalated EBRT as total prescribed dose of ≥75.6 Gy. Using multivariable logistic regression, we examined the association of patient, clinical, and demographic characteristics with the use of dose-escalated EBRT. Results: Overall, 81.6% of men received dose-escalated EBRT during the study period. The use of dose-escalated EBRT did not vary substantially by NCCN risk group. Use of dose-escalated EBRT increased from 70.7% of patients receiving treatment in 2006 to 89.8% of patients receiving treatment in 2011. On multivariable analysis, year of diagnosis and use of intensity modulated radiation therapy were significantly associated with receipt of dose-escalated EBRT. Conclusions: Our study results indicate that dose-escalated EBRT has been widely adopted by radiation oncologists treating prostate cancer in the United States. The proportion of patients receiving dose-escalated EBRT increased nearly 20% between 2006 and 2011. We observed high utilization rates of dose-escalated EBRT within all disease risk groups. Adoption of intensity modulated radiation therapy was strongly associated with use of dose-escalated treatment.

62 RADIOLOGY AND NUCLEAR MEDICINE↗